•  The  Hospital  * 

as  a  Social  Agent  in  the 

Community. 


BY 

Lucy  Cornelia  Catlin,  R.  N. 

Director  of  Social  Service  Work 

and  Executive  Director  of  the  Out-Patient  Department 
Youngstown  Hospital,  Ohio 


Illustrated 


Philadelphia  and  London 

W.  B.  Saunders  Company 

1918 


Copyright,  1918,  by  W.  B.  Saunders  Company 


PRINTED     IN    AMERICA 


PRESS    OF 

8.    SAUNDERS    COMPANY 
PHILADELPHIA 


To  the   Memory  of  my  Aunt  and  Foster  Mother, 
MARGARET  ELIZA  CATLIN 

This  Book  is  Lovingly  Dedicated,  in  Honor 
of  Her  Philanthropic  Spirit  and  Unselfish 
Devotion  to  the  Training  and  Care  of 
Little  Children,  the  Education  of  Young 
Women,  the  Uplift  of  the  Fallen,  the  Aid 
of  Families  in  Need,  Besides  the  Countless 
Manifestations  of  Loving  Thought  for 
Neighbors  and  Friends,  and  the  Living 
Inspiration  of  a  Christ -like  Life  in 
Her  Home 


PREFACE 


IN  offering  this  little  book  to  the  part  of  the  world  which  is 
interested  in  social  work,  especially  those  engaged  in  hospital 
social  service,  the  purpose  of  the  author  has  been  to  present 
certain  principles  which  she  has  found  effective  in  establishing, 
developing,  and  maintaining  the  department  in  hospitals 
where  she  has  been  privileged  to  work.  No  special  literary 
merit  is  claimed  for  it;  no  effort  has  been  made  in  this  direc- 
tion except  to  express  the  thoughts  in  a  clear,  concise,  forceful 
way  to  prove  the  subject  in  hand.  Case  histories  have  been 
selected  to  illustrate  different  points  in  the  text,  and  all  of 
them  are  true  records  of  actual  cases  handled.  Even  the  mere 
reference  to  certain  conditions  and  facts  surrounding  indi- 
viduals or  pertaining  to  the  point  in  question  have  their  origin 
in  the  author's  memory  of  a  real  case.  She  has  thus  endeav- 
ored to  add  weight  to  the  statements  and  arguments  through 
the  avenue  of  true  facts  rather  than  theory.  Probably  any 
cases  recited  can  be  duplicated  by  social  workers  who  read 
them;  they  have  been  chosen  for  illustration  rather  than  for 
any  especially  remarkable  features. 

The  mission  of  the  book  is  expressed  in  the  following  words 
by  one  who  read  the  manuscript:  "Your  book  will  be  a  much 
needed,  guide  for  social  workers,  especially  in  the  new  field  of 
hospital  work  in  smaller  cities."  Few  hospitals  in  communities 
of  any  size  exist  in  these  days  without  a  social  service  depart- 
ment, and  as  the  years  go  by  all  hospitals  will  seek  to  broaden 
their  usefulness  by  contributing  in  this  way  to  public  welfare 
work.  Indeed,  before  many  years  pass  the  author  hopes  to 
see  the  hospital  made  the  center  for  all  the  medico-social  work 
in  the  community. 

7 


8  PREFACE 

It  is  the  author's  hope  that  this  volume  may  find  its  way 
into  the  hands  of  those  who  are  establishing  hospitals  and 
dispensaries  in  new  fields,  and  that  it  may  be  a  help  to  them 
as  well  as  to  those  who  realize  the  need  of  reorganizing  and 
are  at  a  loss  to  know  just  how  to  accomplish  it.  It  was  not 
expected  to  present  suggestions  adapted  to  the  older,  larger 
hospitals;  their  work  differs  in  some  measure.  Social  service 
originated  there,  and  is  now  developing  to  meet  the  needs  in 
smaller  communities  where  co-ordination  of  all  the  forces  in 
welfare  work  is  both  possible  and  desirable. 

The  thought  throughout  the  book  has  been  to  show  how 
the  hospital  may  be  made  an  important  social  agent  in  the 
community,  and  to  present  a  practical,  working  basis.  For 
the  benefit  of  workers  in  entirely  new  fields  forms  of  blanks 
which  have  proved  comprehensive  and  effective  have  been 
reproduced  in  the  Appendix.  Where  it  has  been  possible  case 
histories  have  been  written  in  regular  record  style,  making 
notations  under  successive  dates.  Other  cases  are  put  in  story 
form  for  the  purpose  of  condensing,  yet  they  illustrate  how 
many  of  the  histories  may  be  written  to  good  advantage,  espe- 
cially those  covering  a  long  space  of  time  with  slowly  develop- 
ing features. 

The  author  is  indebted  to  Micheal  M.  Davis,  Jr.,  Director 
of  the  Boston  Dispensary,  for  his  thoughtful  review  of  the 
manuscript,  and  for  valuable  suggestions  made  by  him. 
Many  others  also  have  lent  kindly  advice  and  encouragement 
which  have  helped  to  make  the  book  what  it  is. 

May  this  small  contribution  to  the  cause  of  Hospital 
Social  Service  be  a  guide  to  workers,  and  through  them  a  bless- 
ing to  humanity  which  will  redound  to  the  glory  of  God. 

LUCY  CORNELIA  CATLIN,  R.  N. 
YOUNGSTOWN,  OHIO. 
May,  igi8. 


CONTENTS 


CHAPTER  I 

PAGE 

REASONS  FOR  THE  EXISTENCE  OF  SOCIAL  SERVICE  DEPARTMENTS  IN  HOS- 
PITALS   11 

1.  Completion  of  Service  to  the  Patient 11 

2.  Help  to  Physicians  and  Surgeons  in  Diagnosis  and  Treatment 14 

CHAPTER  II  * 

OUT-PATIENT  DEPARTMENTS,   AND  THE   ADVANTAGE   OF   ESTABLISHING 

THEM  ON  A  SOCIAL  SERVICE  BASIS 17 

1.  Organization  of  Early  Dispensaries  and  the  Development  of  the 

Need  of  Reorganization 17 

CHAPTER  III 
RELATION  TO  AND  CORRELATION  WITH  OTHER  SOCIAL  AGENCIES 23 

CHAPTER  IV 

SICKNESS  OR  INJURY— DIRE  ADVERSITY  AND  THE  TIME  WHEN  SOCIAL 

SERVICE  is  MOST  NEEDED 32 

CHAPTER  V 

SERVICE  TO  THE  INDIVIDUAL,  TO  THE  COMMUNITY,  AND  TO  SOCIETY.  .  40 

1.  The  Tuberculous  Patient 41 

2.  The  Epileptic,  Insane,  and  Feeble-minded  Patient 45 

3.  The  Problem  of  the  Unmarried  Mother 47 

CHAPTER  VI 

THE  PROBLEM  OF  THE  HOSPITAL  CHILD  . .  58 


IO  CONTENTS 

CHAPTER  VII 

PAGE 

HUMAN  ECONOMY  AND  ECONOMY  or  RESOURCES 67 

CHAPTER  VIII 
THE  PLACE  OF  THE  HOSPITAL  IN  PUBLIC  HEALTH  WORK 79 

CONCLUSION 86 

APPENDIX 88 

Facsimiles  of  Blanks  Used  in  the  Social  Service  and  Out-patient 

Departments  of  the  Youngs  town  Hospital 90-108 

Diagram  Illustrating  "Service  and  Co-operation" 109 


INDEX.  .  HI 


"THE    HOSPITAL  AS  A  SOCIAL 
AGENT  IN   THE   COMMUNITY" 


CHAPTER  I 

REASONS  FOR  THE  EXISTENCE  OF  SOCIAL  SER- 
VICE DEPARTMENTS  IN  HOSPITALS 

1.  COMPLETION  OF  SERVICE  TO  THE  PATIENT. 

2.  HELP  TO  PHYSICIANS  AND  SURGEONS  IN  DIAGNOSIS  AND 

TREATMENT. 

THE  rapid  development  of  social  work  in  this  country  the 
past  ten  years  is  but  an  outcome  of  the  growth  in  science  and 
education,  coupled  with  a  broader  philanthropic  spirit  which 
pervades  the  minds  and  hearts  of  our  public-spirited  citizens. 
Sociology  and  political  economy  are  receiving  an  important 
place  in  the  curriculi  of  universities  and  colleges;  scientific 
research  is  enquiring  into  the  causes  of  danger  in  the  industrial 
and  mining  worlds;  schools  of  philanthropy  are  training 
workers  in  the  theory  and  practice  of  social  work.  These 
factors  are  educating  the  public  to  a  realization  of  existing 
social  conditions  and  setting  the  people  to  work  to  find  the 
remedy  for  the  unfavorable  aspects  of  these  conditions. 
Social  work  has  become  as  scientific  as  medical  work;  the 
Russell  Sage  Foundation  is  the  great  social  laboratory,  as 
valuable  to  social  workers  as  Rockefeller  Institute  or  Phipps 
Laboratory  is  to  medical  science. 

XI 


12  "THE  HOSPITAL  AS  A  SOCIAL  AGENT" 

This  is  an  age/when  philosophy  and  science  are  turning  the 
microscope  upon  the'  causes  of  social  sickness  and  maladjust- 
ment,; as  .well  as  v.pon  the  microbes  which  are  the  cause  of  so 
many  of  the  physical  ills.  The  detection  of  the  fundamental 
causes  suggests  the  remedy,  and  treatment  is  much  more 
effective  than  that  which  is  directed  to  symptoms  only. 

The  analogy  between  social  work  and  medical  work  is  so 
close  that  we  may  find  it  profitable  to  call  attention  to  it  here. 
The  social  history  of  an  applicant  for  aid  includes  personal  and 
family  history  and  present  complaint;  then  symptoms  are 
noted,  including  working  ability  of  the  wage  earner,  family 
harmony  or  discord,  degree  of  industry,  immorality  or  drunk- 
enness, poor  management  of  money  or  family  affairs,  and  many 
others.  These  symptoms  are  brought  out  by  the  social 
worker's  investigation,  just  as  the  physical  symptoms  of  a 
patient  are  shown  in  the  doctor's  examination  by  laboratory 
findings,  #-ray,  etc.  After  examination  follows  diagnosis  and 
treatment.  Many  times  the  social  worker,  like  the  physician, 
is  able  to  diagnose  as  soon  as  the  first  history  is  taken,  and  there 
is  no  question  what  the  general  treatment  should  be.  Idio- 
syncrasies must  be  taken  into  consideration  as  the  treatment 
continues,  and  so  each  case  becomes  individual.  Sometimes 
the  nature  of  the  disease  is  so  obscure  that  it  requires  much 
study  and  time  for  development  of  symptoms  before  a  true 
diagnosis  can  be  made.  Nomenclature  and  classification  of 
social  diseases  may  be  as  clearly  defined  as  in  medicine. 
There  is  an  acute  and  a  chronic  state,  climax  and  convales- 
cence, recovery  or  death;  the  social  worker  sees  her  people  in 
all  these  stages,  and  her  responsibility  for  the  treatment  is  as 
great  as  that  of  the  doctor.  Malpractice  on  her  part  may  be 
the  cause  of  the  social  death  of  an  individual,  or  of  the  infec- 
tion of  a  whole  community,  for  sin  and  want  and  poverty  and 
dependence  are  as  contagious  as  smallpox.  Prophylaxis  is  as 


COMPLETION   OF   SERVICE    TO   THE   PATIENT  13 

much  a  part  of  the  social  worker's  responsibility  as  that  of  the 
physician. 

This  is  the  day  of  specialization  in  all  lines  of  work;  it  is 
especially  true  in  medicine,  as  we  often  find  out,  when  it  takes 
the  combined  efforts  of  the  family  physician,  the  surgeon,  the 
eye  specialist,  the  laboratory  man,  the  radiographer,  the 
neurologist,  and  perhaps  a  few  others  to  determine  the  nature 
of  our  trouble  and  to  treat  it.  In  the  field  of  social  work  there 
are  just  as  many  specialists,  and  they  should  be  available  for 
consultation  and  treatment  along  their  special  lines  in  solving 
the  complex  problems  that  arise.  Relief  agencies  are  best 
equipped  to  supply  temporal  needs  and  reconstruct  the  family; 
child  placing  associations,  to  deal  with  the  homeless  child; 
juvenile  courts  with  the  delinquent  youth;  and  the  hospital 
social  service  department  with  medical  problems.  There  are 
accidents  and  emergencies  where  prompt  action  is  necessary. 
The  surgeon  amputates  a  crushed  limb  to  save  a  man's  life; 
the  social  worker  is  called  upon  to  act  just  as  promptly  if  she 
finds  a  baby  left  at  home  with  a  drunken  father  when  the 
mother  has  been  rushed  to  the  hospital  in  a  serious  condition. 
So  the  analogy  might  go  on,  and  to  the  nurse  who  is  doing 
hospital  social  service  work  it  is  very  significant,  for  she  learns 
to  think  and  reason  along  these  same  lines,  so  that  it  becomes  a 
part  of  her  mental  habit. 

That  hospital  social  service  should  have  developed  along 
with  other  philanthropic  organizations  is  only  a  most  natural 
result  of  the  advance  in  science  and  medicine;  an  outcome  of 
the  broader  vision  of  thinking  men  and  women.  The  work 
grew  out  of  its  own  needs,  and  now  is  recognized  as  one  of  the 
special  departments,  as  necessary  in  the  successful  treatment 
of  patients  as  almost  any  of  the  others  in  the  hospital.  The 
hospital  social  worker  is  a  "specialist"  in  the  field  of  social 
work,  and  is  consulted  as  such  by  outside  agencies.  Even  in- 


14  "  THE   HOSPITAL   AS   A    SOCIAL   AGENT  " 

the  hospital  she  is  consultant,  diagnostician,  prescription 
writer  in  social  problems,  and  her  judgment  is  considered 
supreme  in  her  sphere  of  activity. 

It  is  not  necessary  to  review  the  history  of  hospital  social 
service;  it  beginning  hi  the  mind  and  heart  of  a  physician  who 
came  face  to  face  with  the  needs  of  suffering  humanity  in  Jbis 
every-day  hospital  service.  He  recognized  that  these  people 
were  not  getting  all  they  needed,  they  were  not  receiving  the 
benefit  of  the  treatment  that  the  doctors  were  trying  to  give 
them,  yet  what  more  could  the  physicians  do?  The  gap  was 
between  the  hospital,  dispensary,  doctor,  and  the  home. 
The  home,  that  integral  part  of  society  and  of  a  nation  upon 
which  depends  health,  wealth,  and  happiness.  The  social 
service  nurse  has  become  the  bridge  over  this  gap,  and  she  it  is 
who  co-ordinates  the  forces  to  bring  about  the  completion  of 
service  to  the  patient. 

9 

The  case  of  Mrs.  J.  well  illustrates  this.  Mrs.  J.  was  a 
hard-working,  respectable  colored  woman  who  was  referred 
to  the  dispensary  by  a  lady  for  whom  she  worked  as  laundress. 
The  doctor's  examination  showed  a  pelvic  condition  which 
needed  surgical  treatment,  and  also  cardiac  symptoms  re- 
quiring rest  in  bed.  She  was  advised  to  enter  the  hospital  for 
medical  treatment.  This  seemed  to  her  an  impossibility,  and 
the  social  worker,  already  familiar  with  the  family  history, 
came  forward  to  help  her  to  plan  to  carry  out  the  doctor's 
order.  The  social  history  was  as  follows:  Mr.  J.  was  in  the 
penitentiary  for  the  murder  of  their  oldest  daughter.  The 
support  of  the  family,  which  consisted  of  two  boys  and  one 
girl,  devolved  upon  the  mother,  and  she  had  worked  very  hard 
to  have  the  children  cared  for  and  kept  in  school.  The  probate 
court  had  granted  her  a  window's  pension  of  $15.00  a  month, 
but  she  did  laundry  work  beyond  her  strength,  which  had  been 
the  cause  of  her  heart's  overstrain.  Even  before  her  husband's 
murderous  deed  she  had  been  obliged  to  help  in  the  family 
support,  as  he  was  too  shiftless  to  hold  steadily  to  work.  How 


HELP   TO   PHYSICIANS   AND    SURGEONS  15. 

was  she  to  leave  her  children  and  come  to  the  hospital?  That 
was  her  problem.  Following  a  visit  to  the  home  by  the  social 
worker,  Mrs.  J.  was  able  to  arrange  with  two  of  her  friends  to 
take  the  two  younger  children,  and  the  oldest,  a  boy  of  fifteen, 
could  be  left  at  home  with  the  minister  to  keep  a  watchful  eye 
over  him.  She  then  entered  the  hospital  as  a  city-paid  case 
for  the  rest  and  medical  treatment  she  was  so  much  in  need  of. 
Three  weeks  showed  a  marked  improvement,  the  medical 
doctor  called  the  surgeon  in  consultation,  and  the  decision  was 
that  an  operation  was  necessary  to  put  her  in  shape  to  take 
care  of  her  family  as  she  should,  and  the  doctors  advised  her 
to  remain  for  it,  as  she  was  in  better  condition  than  she  would 
be  if  she  went  home  to  her  work  again.  But  she  said, 
"  Doctors,  I  cannot  stay,  for  I  cannot  leave  my  family  so  long. " 
The  facts  were  reported  to  the  social  worker,  who  talked  over 
the  matter  with  her,  and  set  to  work  to  arrange  the  home  affairs 
so  that  it  would  be  possible  for  her  to  remain  in  the  hospital 
for  the  operation  at  this  time.  The  pastor  was  called  upon  to 
look  after  the  oldest  boy  and  get  him  employment  if  possible, 
a  friend  to  keep  the  girl,  and  the  Fresh  Air  Camp  to  take  the 
youngest  boy.  The  minister  advanced  the  money  for  the  pay- 
ment of  insurance  dues,  which  she  was  anxious  to  keep  up,  as 
this  provided  in  part  for  her  children  should  she  be  taken. 
Her  mind  was  then  at  rest,  and  she  went  through  the  operation 
well,  made  a  good  recovery,  and  returned  to  her  family  in 
condition  to  be  of  service  to  them.  A  year  and  a  half  has 
passed  since  then,  and  she  has  gone  back  to  her  former  work, 
her  son  has  secured  a  good  position,  and  the  family  is  not  only 
self-sustaining,  but  they  have  saved  enough  to  pay  off  some 
old  debts  which  Mr.  J.  incurred  before  he  went  to  the  peniten- 
tiary. How  incomplete  would  have  been  the  doctor's  and  the 
hospital's  service  to  this  woman  if  the  work  had  stopped  at  the 
dispensary  after  the  examination  had  been  made  and  advice 
given. 


This  example  illustrates  the  advantage  of  the  social  history 
in  the  physician's  diagnosis  and  of  the  social  service  in  his 
treatment.  It  also  shows  the  importance  of  team  work  be- 


l6          THE  HOSPITAL  AS  A  SOCIAL  AGENT  " 

tween  social  worker  and  doctor  in  order  to  secure  the  best 
social  and  economic  results.  The  dispensary  patient  or  the 
free  hospital  patient  is  entitled^  to  the  best  medical  treatment 
which  can  be  offered.  The  staff  doctor  who  is  giving  his  time 
to  them  is  entitled  to  every  aid  from  the  social  worker  to  carry 
out  adequate  treatment.  Without  it  his  efforts  may  be  futile, 
and  his  discouragement  will  lead  to  indifference  or  a  desire  to 
make  the  patient  the  victim  of  experimentation.  If  this  re- 
sults, medical  and  hospital  standards  are  lowered,  public  con- 
fidence is  lost,  and  best  service  to  the  individual,  to  the  com- 
munity, and  to  society  is  withheld. 

The  time  is  coming,  and  may  not  be  far  distant,  when  hos- 
pital staff  physicians  will  receive  compensation  for  their  pro- 
fessional services  to  so-called  free  patients,  not  because  they 
have  not  given  their  best  service  in  the  past,  but  because  the 
public  demands  a  greater  service  than  doctors  are  able  to  give 
freely  and  at  the  same  time  earn  their  livelihood.  The  patient 
who,  by  reason  of  circumstances,  is  obliged  to  seek  free  medical 
advice  is  entitled  to  the  best  treatment  that  can  be  provided, 
not  alone  for  his  own  sake,  but  for  the  sake  of  the  community, 
which  is  thus  spared  the  danger  from  spread  of  disease,  and 
from  the  necessity  of  caring  for  dependent  individuals. 

By  maintaining  a  high  standard  of  medical  efficiency  hos- 
pitals are  in  a  position  to  render  the  highest  service  to  the  com- 
munity in  public  health  work,  and  such  an  equipment  will  com- 
mand the  respect  and  confidence  of  the  public,  especially  if 
it  is  coupled  with  an  efficient  social  service  department. 


CHAPTER  II 

OUT-PATIENT  DEPARTMENTS  AND  THE  ADVAN- 
TAGE OF  ESTABLISHING  THEM  ON  A  SOCIAL 
SERVICE  BASIS 

ORGANIZATION  OF  EARLY  DISPENSARIES  AND  THE  DEVELOP- 
MENT OF  THE  NEED  OF  REORGANIZATION 

THE  need  of  the  unification  of  social  service  work  in  hospital 
wards  and  in  the  out-patient  department  cannot  be  too  strongly 
emphasized.  The  social  service  department  of  a  hospital 
should  embrace  all  departments  of  the  organization  where 
social  work  is  needed,  the  worker  being  at  least  consultant  if 
she  is  not  the  logical  person  to  follow  out  details.  Between 
the  dispensary  and  the  hospital  there  should  be  the  closest 
relation  both  as  regards  medical  and  social  work.  Whether 
or  not  the  same  medical  staff  serves  in  both  places  at  the  same 
time,  there  should  be  co-operation  and  co-ordination  for  the 
best  interests  of  all,  and  the  social  service  department  links 
these  forces  and  interests.  The  hospital  organization  today 
stands  as  one  of  the  chief  agents  of  public  health,  it  cares  for 
the  injured  and  acutely  ill  in  its  surgical  and  medical  wards, 
for  those  suffering  from  contagious  diseases  in  its  isolation 
ward,  and  for  ambulatory  patients  in  its  out-patient  depart- 
ment. Its  medical,  nursing,  and  social  service  equipment  must 
be  adequate  to  meet  this  responsibility. 

Social  service  needs  were  first  recognized  in  the  dispensary, 
and  the  department  developed  from  this  point  to  include 

17 


i8  "THE  HOSPITAL  AS  A  SOCIAL  AGENT " 

hospital  ward  patients.  Let  us,  therefore,  look  back  into  the 
history  of  dispensaries  that  we  may  better  account  for  the 
development  of  the  need  for  reorganization. 

As  the  root  of  the  word  implies,  a  dispensary  is  a  place 
where  certain  things  are  dispensed  to  those  who  ask,  and  the 
term  came  to  be  applied  more  exclusively  to  the  place  where 
drugs  or  medicines  were  given  out  free  of  charge  to  needy 
bably  there  have  been  dispensaries  in  some  form 
'ever  since  there  have  been  doctors,  for  sickness  comes  to  rich 
and  poor  alike  and  seeks  relief,  but  the  wide-spread  establish- 
ment of  dispensaries  came  with  the  development  of  medical 
education.  It  was  a  demand  of  medical  schools  in  search  of 
clinical  material,  and  the  demand  is  justified  now  as  well  as  it 
was  then.  The  physician  with  the  large  experience  in  free 
hospital  service  is  the  one  who  gains  and  holds  the  greatest 
public  confidence/  It  is  an  old  saying  that  "physicians  ride  to 
eminence  on  the  backs  of  the  poor."  Many  of  us  owe  our 
lives  to  physicians  whose  skill  has  been  acquired  and  ex- 
perience gained  in  the  free  treatment  of  patients. 

Dispensaries  have  an  important  field  in  medical  education 
not  only  for  the  student  of  medicine,  but  for  the  postgraduate, 
and  recognition  must  be  given  to  this  phase  of  the  work.  But 
there  is  another  side  which  now  demands  attention  and  which 
has  led  to  the  reorganization  of  dispensary  work.  Individual, 
community,  and  society  interests  occupy  the  part  of  the  field 
now  being  cultivated,  and  which  calls  for  the  united  efforts  of 
physicians  and  social  workers,  the  "team  work,"  as  Dr.  Cabot 
calls  it,  which  is  so  essential  to  success.  This  large  part  of  the 
great  field  of  human  life  and  economy  is  now  being  occupied 
by  experts  who  have  driven  their  stakes,  laid  their  claims,  and 
proved  their  rights.  It  now  remains  for  these  experts  to  show 
what  the  field  will  yield  for  the  betterment  of  the  human  race 
under  their  scientific  cultivation. 


ORGANIZATION   OF   EARLY   DISPENSARIES  1Q 

It  is  only  within  the  last  decade  that  newly  organized  dis- 
pensaries have  been  placed  upon  a  social  service  basis.  Here- 
tofore they  were  established  on  a  medical  basis  because  the 
medical  side  of  the  work  was  naturally  the  first  thought,  and 
dispensaries  connected  with  old  hospitals  or  with  teaching 
hospitals  will  no  doubt  remain  for  some  time  to  come  under 
medical  supervision.  In  these  dispensaries  there  has  been 
introduced  the  Social  Service  Department  to  which  the  doctors 
refer  cases  in  need  of  any  kind  of  social  service.  Many  of  these 
departments  are  covering  all  cases  in  certain  clinics  where 
there  is  always  need  for  service.  Few  surgical  clinics  require 
general  follow-up  work,  and  those  patients  who  do  may  be 
easily  referred  to  a  social  worker.  With  medical  cases  the 
need  is  greater.  All  tuberculous  patients,  all  orthopedic  cases, 
practically  all  children,  all  mothers  with  babies,  all  gonorrheal 
and  syphilitic  patients  should  be  social  service  cases  for  more 
or  less  intensive  work.  This  plan  is  generally  followed  now  in 
the  larger,  older  dispensaries  where  the  daily  attendance  is  too 
large  to  make  any  other  procedure  possible. 

Whatever  the  organization,  or  whatever  the  plan  of  work, 
the  department  no  longer  needs  an  excuse  for  its  existence.  The 
importance  of  social  work  in  connection  with  hospitals  and  dis- 
pensaries has  been  established,  and  is  now  recognized  as  a 
necessary  factor  in  completing  the  hospital's  service  as  a  social 
agent  in  the  community. 

The  superintendent  of  one  of  our  large  city  hospitals  bit- 
terly opposed  the  introduction  of  social  service  into  his  institu- 
tion, and  allowed  it  only  under  protest.  A  few  years  after, 
when  the  department  was  well  established  and  demonstrated 
every  day  its  value,  this  same  superintendent  was  asked  how 
he  regarded  it  then.  His  prompt  reply  was,  "I  consider  it  of 
inestimable  value;  I  would  rather  give  up  almost  any  depart- 
ment in  the  hospital  than  social  service." 


20  "THE  HOSPITAL  AS  A  SOCIAL  AGENT " 

In  the  general  public  health  program  it  is  indispensable, 
and  herein  its  latent  possibilities  lie.  What  social  worker  is 
better  able  to  know  the  menace  of  physical  defects  and  disease 
to  the  individual  and  society  than  the  nurse  doing  social  work 
in  the  hospital?  And  who  is  in  a  better  position  to  remedy 
these  defects,  and  to  bring  about  the  cure  or  isolation  of  these 
diseases  than  this  nurse? 

The  hospital  has  always  been  an  important  agent  in  the 
community  for  the  benefit  of  society  hi  caring  for  the  sick  and 
injured,  and  as  medical  science  and  surgical  skill  have  devel- 
oped, the  hospital  has  grown  wonderfully  in  its  usefulness.  But 
with  the  introduction  of  the  social  worker  the  hospital  has 
been  placed  in  the  forefront  as  a  medicosocial  agent,  and  its 
service  as  such  depends  upon  the  scientific,  practical,  sensible 
development  of  the  social  service  department.  Hospitals  must 
realize  their  responsibility  in  this  direction  and  turn  their 
attention  to  the  working  out  of  the  underlying  principles. 

As  new  lines  of  work  spring  up  which  especially  appeal  to 
the  public  mind,  they  are  bound  to  pass  through  a  period  of 
excrescent  growth,  they  are  like  wounds  which  throw  out 
excessive  granular  tissue  in  their  overabundant  effort  to  heal. 
Generally  speaking,  hospital  social  service  has  suffered  as  little 
in  this  direction  as  any  of  the  lines  of  benevolent  work  of  recent 
development.  Fortunately  for  the  work  its  pioneers  have 
been  men  and  women  of  conservative  thought,  broad  vision, 
and  practical  experience,  and  they  have  laid  foundations  upon 
which  a  superstructure  is  being  built  that  will  stand. 

Let  us  urge,  therefore,  that  hospitals  in  the  smaller  com- 
munities who  are  planning  to  establish  social  service  work  keep 
in  mind  their  responsibility  as  a  social  agent  in  the  com- 
munity; then,  when  the  dispensary  is  opened,  it  should  be  es- 
tablished on  a  social  service  basis  and  come  under  the  direction 
of  the  social  service  department.  This  will  bring  about  the 


NEED   OF   REORGANIZATION  21 

unification  spoken  of  in  the  first  part  of  this  chapter,  the  ad- 
vantages of  which  will  be  shown  later. 

May  we  describe  a  model  organization  along  the  lines  of  the 
theories  set  forth,  that  we  may  best  illustrate  the  reasons  for 
such  a  plan. 

One  of  the  first  requisites  is  the  selection  of  a  well-qualified 
woman,  preferably  a  graduate  nurse,  but  one  who  has  a  broad 
conception  of  the  hospital's  opportunity  and  obligation,  the 
patient's  needs,  the  doctor's  service,  and  the  community's 
problems.  She  should  be  the  admitting  officer  in  the  dis- 
pensary, taking  the  social  history  of  all  applicants,  basing  her 
judgment  of  the  eligibility  of  the  patient  for  free  treatment 
upon  this  history,  and  upon  the  liability  of  his  becoming  a 
menace  or  a  burden  to  the  public  if  treatment  is  denied. 
With  this  initial  touch  the  social  worker  is  prepared  to  be  of 
special  service  to  the  patient  and  to  the  doctor  whenever  there 
is  need,  and,  by  further  investigation,  to  take  up  any  deeper 
problems  that  are  indicated. 

The  head  worker  should  be  the  executive  director  of  the 
dispensary,  responsible  for  the  proper  conduct  of  the  operation 
•of  its  service,  and  helping  to  lay  out  its  policies  and  plans  for 
development.  She  should  see  that  every  possible  aid  is  given 
the  doctors  in  the  examination  and  treatment  of  patients,  to 
conserve  their  time,  and  to  complete  their  service.  Through 
her  assistants,  follow-up  work  should  be  done  wherever  it  is 
necessary  to  carry  the  doctor's  directions  to  the  home,  to  secure 
the  patient's  return  to  the  dispensary,  or  to  arrange  for  relief 
or  transfer  to  other  agencies  or  institutions. 

If,  after  examination,  a  patient  is  referred  to  the  hospital 
wards  for  treatment  or  operation,  arrangements  may  be  made 
through  the  social  service  department  for  his  admission  either 
as  a  free  or  part-pay  patient,  suiting  the  time  for  his  admission 
to  the  needs  of  the  case,  to  the  family  convenience,  or  to  the 


22        "  THE  HOSPITAL  AS  A  SOCIAL  AGENT  " 

number  of  available  beds  on  the  ward.  Often  the  social  worker 
may  help  to  persuade  or  assist  in  overcoming  prejudices  or  dif- 
ficulties, through  her  friendly  interest  and  advice.  This  case 
may  be  followed  into  the  hospital  with  any  social  service  that 
is  needed,  and  if  necessary  returned  to  the  dispensary  for  treat- 
ment or  observation.  Thus  the  completion  of  service  to  the 
patient  is  accomplished,  and  the  doctor  is  able  to  see  the  results 
of  his  work  in  diagnosis  in  the  treatment  which  it  is  possible 
to  have  carried  out.  Team-work  like  this,  bringing  such  satis- 
factory results  which  spread  out  into  the  community,  effecting 
the  home-life  of  its  members,  and  proving  to  the  medical 
profession  the  possibilities  of  scientific  treatment,  furnishes 
just  encouragement  to  both  social  workers  and  doctors.  Both 
are  inspired  to  put  forth  best  efforts  for  the  amelioration  of 
physical  suffering  and  social  distress,  and  with  such  co-opera- 
tion the  success  of  the  dispensary  is  assured. 

It  must  be  the  definite  purpose  of  the  social  worker  either 
in  the  hospital  or  dispensary,  first,  to  procure  adequate  treat- 
ment for  the  alleviation  of  suffering,  or  for  the  removal  of  a 
handicap  in  the  individual;  second,  to  assist  in  combating 
disease  in  the  community;  and  third,  to  take  up  the  more  dis- 
tinct social  problems  which  (Affect  the  life  and  health  of  the 
community  and  the  state  of  society. 

The  province  of  the  dispensary  is  extending  far  beyond  the 
clinic  walls,  until  it  now  reaches  out  into  the  community  as  a 
public  agent.  This  is  the  need  which  has  brought  about  a 
readjustment  by  the  injection  into  the  operation  of  dispen- 
saries social  service  principles  and  public  welfare  interests. 


CHAPTER  III 

RELATION  TO  AND  CORRELATION  WITH  OTHER 

SOCIAL  AGENCIES 

t 

THE  social  worker  in  her  travels  about  the  city  for  the  pur- 
pose of  investigation  and  service  makes  many  trips  on  the 
street  car,  and  has  many  waits  which  are  unavoidable,  but 
she  learns  to  use  these  hours  of  apparent  waste  in  the  study  of 
human  nature  with  which  she  comes  in  contact,  or  in  thinking 
out  some  of  the  life  problems  that  are  puzzling  her.  She 
comes  in  touch  with  many  factors  which  constitute  and  influ- 
ence the  life  of  individuals,  and  observes  their  setting  in  society 
and  in  the  community.  Indeed,  the  many  hours  of  travel  or 
waiting  are  precious  ones  if  they  are  used  for  observation  and 
thought. 

On  the  car  this  morning  is  a  working  man  with  his  dinner- 
pail  going  to  work  to  provide  food,  shelter,  and  clothing  for  the 
family  at  home.  The  mind  at  once  pictures  the  home,  with 
the  influences  there  which  make  or  break  society,  and  we  real- 
ize our  responsibility  in  helping  to  maintain  and  upbuild  that 
home. 

In  the  corner,  sitting  all  in  a  heap,  is  a  poor  specimen  of 
drunken  humanity,  sleeping  his  way  along,  scarcely  aware  of 
any  desired  destination,  empty  handed  and  empty  headed,  an 
undesirable  individual,  and  seemingly  hopeless.  It  is  not  hard 
to  trace  the  train  of  influences  which  are  responsible  for  this 
downfall,  and  as  our  eyes  glance  out  of  the  car  window  while 
we  pass  through  the  main  street,  the  saloon,  which  is  much 

23 


24  "  THE   HOSPITAL  AS   A   SOCIAL  AGENT  " 

in  evidence,  points  out  the  cause  of  this  effect  with  which  we 
are  riding. 

At  Griffith  Street,  a  man  well  along  in  years  and  rather 
under  par  physically,  boards  the  car,  carrying  a  few  pieces  of 
aluminum  ware.  We  recognize  him  as  a  patient  who  has 
visited  the  dispensary,  and  we  recall  the  history  he  gave.  He 
is  a  widower,  without  children  who  are  willing  to  make  a  home 
for  him,  past  the  age  to  be  employed  for  heavy,  responsible 
work,  yet  he  maintains  a  worthy  spirit  of  independence  by 
endeavoring  to  earn  a  respectable  living  for  himself.  We 
know  from  the  doctor's  diagnosis  that  his  earning  capacity  will 
not  long  be  sufficient  to  meet  even  the  bare  cost  of  his  living, 
and  a  feeling  of  pity  passes  over  us  as  we  contemplate  what  his 
future  may  be. 

Next,  the  visiting  nurse  on  her  rounds  of  ministration  joins 
us,  and  she  tells  of  a  family  which  she  has  just  left,  where  three 
of  the  children  are  fighting  the  battle  with  pneumonia.  The 
father  must  keep  at  his  work  to  meet  the  extra  expense  brought 
by  this  sickness,  for  the  children  must  be  spared  if  it  takes  his 
last  penny  to  pay  the  doctor.  The  mother  is  left  at  home  to 
watch  and  wait  for  the  crisis  which  will  decide  the  battle.  We 
are  reminded  of  the  old  song  with  its  chorus, 

"For  men  must  work  and  women  must  weep, 
For  there's  little  to  earn  and  many  to  keep." 

But  we  cannot  muse  longer,  for  the  car  has  reached  the 
street  where  we  must  get  off.  Up  the  hill  we  go,  turn  to  the 
right  and  enter  a  house,  following  the  lead  of  a  lad  of  ten  years 
to  the  room  where  his  mother  lies  in  bed.  She  is  about  to  be 
confined  and  is  already  in  labor,  yet  has  no  doctor  to  attend  her, 
no  one  to  take  care  of  her  and  the  baby,  no  fire  in  the  house, 
very  little  food  for  the  other  four  children,  no  money,  and  last, 
but  by  no  means  least,  her  husband  has  left  her  in  such  a  plight. 


CORRELATION  WITH   OTHER   SOCIAL   AGENCIES  25 

What  can  be  done?  It  is  no  place  for  a  baby  to  come,  even  if 
a  doctor  can  be  secured,  and  there  is  no  time  to  be  lost.  She 
must  go  to  the  hospital,  and  a  neighbor  sought  to  care  for  the 
children  until  the  next  day,  when  some  arrangement  can  be 
made  for  them  until  the  mother  can  return.  The  bed  upon 
which  the  woman  lay  was  the  only  one  they  had,  the  children's 
mattresses  lay  on  the  floor,  and  the  rooms  were  almost  divested 
of  furniture.  They  had  bought  on  the  instalment  plan,  and 
most  of  the  furniture  had  been  confiscated  because  of  failure 
to  make  payments.  The  little  woman,  a  Hungarian,  was 
earnest  and  courageous,  she  had  trained  her  children  as  best 
she  could,  her  house  was  neat  and  clean,  but  her  Jewish  hus- 
band had  a  habit  of  disappearing  at  this  critical  hour  and 
leaving  her  to  the  mercy  of  passersby,  she  being  fortunate  if 
the  "Good  Samaritan"  chanced  that  way. 

As  we  go  on  our  way  to  work  out  this  problem  we  find  our- 
selves wondering  why  this  maladjustment  exists,  what  it  is  in 
man  that  freezes  his  heart  against  his  duty  at  such  a  moment 
when  woman  faces  the  anguish  and  suffering  for  him  and  his 
child? 

Our  next  visit  is  to  the  basement  of  a  dirty,  dingy  building, 
where  we  find  a  drunken  man,  a  blind  woman,  a  feeble- 
minded boy  of  fifteen,  and  a  six-year-old  girl  who  has  no  cloth- 
ing on  but  a  dress,  and  her  hair  is  one  mass  of  filth  and  vermin 
and  scales.  The  tin  cans  from  which  the  family  ate  their  last 
meal  are  on  the  dirty  table,  the  corners  of  the  room  are  filled 
with  refuse,  dirt  and  tin  cans,  where  it  has  been  swept  to  make 
room  in  the  middle  of  the  floor  to  get  about.  The  feeling  of 
revolt  which  we  have  and  the  creeping,  crawling  sensations 
may  easily  be  imagined.  We  retrace  our  steps  to  the  car, 
realizing  that  there  is  little  more  than  the  animal  nature  in 
such  human  beings. 

On  the  return  trip  to  the  hospital  the  car  is  delayed  some 


26  "THE  HOSPITAL  AS  A  SOCIAL  AGENT" 

time  by  a  large  traction  engine  belonging  to  a  construction 
company  which  is  relaying  and  reconstructing  the  street  car 
track.  The  powerful  engine  is  driving  its  shovel  under  the 
track,  tearing  it  up  and  lifting  ties,  brick,  dirt,  and  everything 
into  the  air.  Then  slowly  the  great  arm  swings  about,  the 
engineer  manipulates  the  levers,  and  the  shovel  lets  go  of  its 
load,  dumps  it  into  carts  to  be  hauled  away  where  materials 
are  sorted,  some  thrown  away,  and  others  set  aside  for  the  work 
of  reconstruction.  A  short  distance  up  the  track  the  other 
machinery  is  at  work  laying  the  rails  and  filling  in  with  gravel 
and  cement  and  we  see  the  completed  work. 

Efficient  social  work  in  the  community  is  just  as  construc- 
tive as  this  material  work,  differing  only  in  completeness  of 
finish  because  of  the  human  material  with  which  we  have  to 
deal.  It  is  like  a  great  chain  in  the  hands  of  the  Almighty  to 
lift  people  from  the  bed  of  want,  degradation,  poverty,  sick- 
ness, dependence,  and  unwholesome  surroundings,  to  swing 
them  about  and  drop  them  on  new  ground  where  there  are 
new  opportunities  for  readjustment.  Each  social  agent  in  the 
community  is  a  link  in  this  chain,  and  effective  work  depends 
upon  the  efficiency  of  each  agent  and  the  working  together  of 
all.  The  day  of  miracles  is  past.  The  Almighty  chooses  to  work 
through  human  agents,  but  how  can  He  lift  the  load  if  even  one 
of  the  links  of  His  chain  is  weak,  or  if  all  do  not  pull  together? 
Efficiency  and  co-operation  must  be  welded  together  to  make 
each  link,  if  the  work  of  social  readjustment  and  reconstruc- 
tion is  to  be  accomplished. 

This  crude  figure  illustrates  what  is  meant  by  the  relation 
of  hospital  social  service  to,  and  its  correlation  with,  other 
social  agencies  in  the  community.  The  social  service  depart- 
ment of  the  hospital  should  be  equipped  to  take  care  of  the 
medicosocial  problems  which  come  to  the  hospital  or  dispen- 
sary, and  its  work  should  be  so  efficient  that  public  confidence 


CORRELATION  WITH   OTHER   SOCIAL  AGENCIES  27 

is  assured.  On  the  other  hand,  it  cannot  be  adequate  to 
proper  child  placing,  or  family  reconstruction,  or  relief  work, 
and  therefore  it  is  dependent  upon  other  organizations. 

Let  us  recall  the  cases  cited  in  the  first  part  of  this  chapter, 
and  point  out  the  correlation  and  interdependence  that  is  abso- 
lutely necessary  for  the  most  successful  accomplishments  in 
social  welfare.  First,  here  is  the  man  with  the  dinner-pail,  all 
honor  to  him  and  his  insignia,  the  pail.  He  represents  an 
honest  struggle  for  independence,  the  man  with  the  steady  job, 
equal  to  the  support  of  himself  and  his  family  when  work  is 
plenty,  and  all  goes  well  with  the  wife  and  children.  But  there 
is  no  surplus,  and  when  sickness  or  adversity  comes,  his  re- 
sources are  soon  exhausted  and  he  must  have  help.  His  own 
injury  or  the  illness  of  one  of  the  family  may  be  the  means  of 
their  introduction  to  the  hospital  social  worker,  and  her  first 
duty  is  to  help  bring  about  adequate  medical  treatment  by  co- 
operating with  the  doctor  in  every  possible  way,  acquainting 
him  with  the  social  history  if  it  will  aid  in  his  decision.  It  is 
the  responsibility  of  social  workers  to  preserve  the  home  unless 
the  good  of  the  individuals  or  of  the  community  demands  that 
it  be  broken  up.  All  the  forces  that  are  necessary  to  be  called 
into  play,  therefore,  should  be  directed  to  the  preservation  of 
this  home  where  sickness  or  injury  has  made  its  inroad.  The 
agencies  giving  hospital  care,  relief,  temporary  loans,  or  tem- 
porary care  for  the  children  should  work  shoulder  to  shoulder 
to  this  end. 

This  poor  fellow  in  the  corner  of  the  car  is  most  likely  to 
fall  a  victim  of  accident  and  be  sent  to  the  hospital  for  repairs. 
Possibly  a  limb  must  be  amputated,  then  as  the  days  go  by  the 
social  worker  asks  what  of  the  future  for  this  man,  crippled, 
penniless,  homeless,  morally  broken.  The  day  is  coming  when 
the  doctors  will  discharge  him  "cured,"  but  where  is  he  going? 
What  is  he  going  to  do?  He  is  a  more  useless  member  of  society 


28  "  THE  HOSPITAL  AS   A   SOCIAL  AGENT  " 

than  he  was  before.  Disregarding  for  the  time  being  the  man 
himself,  with  whom  it  is  hard  to  sympathize,  what  is  best  to  do 
with  him  for  the  community's  sake  to  relieve  its  burden? 
The  treatment  is  evident — reform  the  man,  secure  for  him  an 
artificial  limb,  then  find  proper  surroundings  and  get  him  work. 
This  is  more  easily  said  than  done,  but  work  must  be  directed 
toward  this  end,  and  it  will  take  the  combined  efforts  of  a 
number  of  individuals  and  agencies  to  even  make  a  beginning 
toward  success.  Incidentally,  the  social  worker  should  use 
all  the  influence  which  she  can  bring  to  bear  upon  the  abolish- 
ment of  the  source  of  evil  which  has  been  the  means  of  bring- 
ing about  this  combination  of  disasters. 

The  man  with  the  aluminum  ware,  whom  we  are  treating 
in  the  dispensary,  calls  forth  our  interest  because  the  time  is 
coming  when  he  will  be  obliged  to  give  up  his  independent  life, 
as  he  will  no  longer  be  able  to  be  self-supporting.  We  may 
prepare  for  this  time  by  a  personal,  friendly  interest  shown  in 
his  welfare  as  we  see  him  from  time  to  time,  or  possibly  by 
putting  him  in  touch  with  some  church  or  some  organization 
which  may  be  able  to  find  a  better  home  and  other  occupation 
with  less  risks  and  surer  pay.  It  is  not  enough  for  that  man 
to  merely  eke  out  an  existence  as  he  is  doing,  he  needs  the  friend 
who  will  help  him  with  the  burden  which  is  too  heavy  as  he  is 
trying  to  carry  it.  With  his  physical  strength  conserved,  he 
may  be  able  for  a  longer  time  to  maintain  his  independence. 
So,  if  the  social  worker  cannot  enter  into  this  problem  to  carry 
it  out  successfully,  she  should  call  upon  the  agent  which  is  the 
best  in  this  individual  case  to  give  the  most  adequate  service. 

The  district  nurse  reminds  us  of  one  of  the  most  important 
co-operating  organizations.  It  is  she  who  will  go  to  the  home 
and  treat  the  baby's  discharging  ear  after  the  dispensary  doctor 
has  prescribed  for  it;  she  will  watch  for  unfavorable  symptoms, 
and  send  the  mother  back  with  the  child  for  further  examination 


CORRELATION  WITH   OTHER   SOCIAL  AGENCIES  2Q 

and  treatment.  The  district  nurse  is  one  of  the  first  aids  to  the 
social  service  department  in  the  hospital. 

The  woman  deserted  by  her  husband,  and  left  so  desolate 
when  in  the  throes  of  childbirth,  asks  nothing,  but  her  need 
calls  for  prompt,  concerted  action.  The  agencies  co-operating 
are  the  hospital,  the  neighbor  who  takes  the  four  children  in  her 
home  for  temporary  care,  the  ambulance  service,  the  Jewish 
Charities,  the  husband's  mother  and  sister,  the  juvenile  court, 
and  the  Children's  Home.  Her  baby 'was  born  soon  after  she 
reached  the  hospital,  the  boys  were  committed  temporarily  to 
the  Home,  the  little  girls  went  to  the  grandparents'  to  stay, 
and  the  Jewish  Charities  took  up  the  family  problem  when 
the  mother  returned  from  the  hospital  and  the  family  was  re- 
united except  for  the  return  of  the  father. 

The  next  home,  where  drunkenness,  blindness,  feeblemind- 
edness,- and  filth  are  combined,  we  see  no  way  except  to  break 
it  up,  for  the  sake  of  the  children,  the  mother,  and  the  com- 
munity. The  first  touch  with  this  family  was  when  the  woman 
came  to  the  dispensary  with  her  eyes  in  very  bad  condition 
and  her  sight  much  impaired.  With  treatment  prescribed, 
the  case  was  referred  to  the  visiting  nurses  for  supervisory 
care  in  the  home.  She  did  not  improve,  and  the  nurse  tried 
for  four  weeks  to  get  her  to  return  to  the  dispensary,  but  in- 
stead she  found  her  way  to  a  general  practitioner,  who  pre- 
scribed certain  drops  for  her  eyes.  After  a  few  applications  of 
this  drug  her  eyes  were  so  much  worse  that  she  returned  to  the 
dispensary,  and  it  was  then  discovered  by  the  oculist  that  a 
drug  had  been  used  which  was  contraindicated  in  the  disease 
from  which  she  was  suffering  and  her  sight  was  almost  gone. 
Although  by  this  time  her  eyes  were  past  repair  she  was  ad- 
mitted to  the  hospital  wards,  that  everything  possible  might 
be  done  in  the  effort  to  save  her  vision.  It  was  unavailing,  for 
the  harm  had  been  done,  she  was  hopelessly  blind.  Followed 


30  "THE  HOSPITAL  AS  A  SOCIAL  AGENT" 

back  to  the  home  when  she  left  the  hospital,  accompanied  by 
the  blind  teacher,  we  found  the  hopeless  condition  described 
above,  the  filth  being  the  most  desperate  factor.  The  little 
girl  was  sadly  in  need  of  attention,  as  the  condition  of  her  head 
was  due  to  filth  and  neglect,  the  boy  of  fifteen  had  a  mind  of  a 
four-year-old  child,  and  he  had  been  excluded  from  school  be- 
cause he  was  a  moral  pervert  and  a  menace  to  other  pupils. 
The  man,  a  drunken,  shiftless  being,  was  abusive  and  did  not 
provide  for  his  family;  they  could  not  buy  from  neighboring 
stores  without  money,  as  their  credit  was  gone,  and  the  woman 
and  children  often  went  hungry. 

Here  we  have  a  most  desperate  situation  that  can  only  be  re- 
lieved by  disintegrating  the  home.  This  is  accomplished  by  the 
Charity  Organization  Society's  investigation,  and  the  prosecu- 
tion of  the  parents  for  neglect  of  the  children  by  the  Humane 
Society  in  the  juvenile  court.  Hospital  social  workers,  visit- 
ing nurses,  school  teacher,  resident  of  a  neighborhood  settle- 
ment house,  and  the  truant  officer  are  called  as  witnesses,  and 
the  judge  sends  the  little  girl  to  the  Children's  Home,  the  boy 
to  the  State  Bureau  of  Juvenile  Research,  and  the  mother  to  a 
blind  industrial  home.  There  being  no  adequate  means  in  the 
city  to  forcibly  put  the  man  to  work  as  an  act  of  punishment  or 
for  the  purpose  of  keeping  him  out  of  trouble,  he  was  left  to  his 
own  destruction  through  the  sure  channel  of  the  police  court. 

The  hospital  social  service  department  is  not  fitted  to  meet 
all  these  situations,  neither  should  it  expect  to  be;  others  are 
better  fitted  by  position,  equipment  or  authority  to  work 
out  the  more  intensive,  complex  social  problems,  or,  in  other 
words,  they  are  specialists  along  their  different  lines,  and  should 
be  consulted  as  such. 

Duplication  of  work  is  avoided  by  such  co-operative  plans. 
A  program  well  thought  out  to  meet  the  requirements  of  a  cer- 
tain family  problem  may  be  entirely  upset  by  independent,  in- 


CORRELATION  WITH   OTHER   SOCIAL  AGENCIES  31 

dividual  work,  and  the  good  that  might  be  accomplished  is  com- 
pletely overthrown.  Hospital  social  workers  have  no  more 
right  to  interfere  in  general  family  reconstruction  that  is  being 
handled  by  associated  charities  than  the  latter  have  to  dictate 
the  kind  of  treatment  a  patient  should  receive  whom  they  are 
sending  to  the  hospital.  This  sort  of  interference  indicates 
low  standards  of  social  work,  a  narrow  conception  of  the  indi- 
vidual and  community  needs,  and  should  not  be  tolerated. 
The  interests  at  stake  are  too  vital  to  be  dealt  with  in  any  spirit 
of  self-interest  or  dominance  of  opinion.  Social  work  in  the 
community  should  be  as  complete  a  unit  in  operation  as  the 
medical  and  social  work  in  a  hospital,  which  functionates  as  an 
individual,  each  department  being  available  for  consultation 
in  any  case  where  it  is  indicated. 

It  is  most  gratifying  to  note  the  splendid  organization  that 
has  been  effected  in  some  of  our  cities,  and  we  believe  it  ap- 
proaches the  ideal,  at  least  it  gives  us  a  basis  upon  which  to 
work  out  the  best  plan  for  co-ordination  and  correlation  of 
forces  for  community  welfare  work.  It  is  not  a  part  of  the 
subject  of  this  book  to  go  into  the  details  of  such  an  organiza- 
tion, but  we  hail  the  day  when  there  shall  be  a  unified  central 
plan  for  the  management  of  all  welfare  agencies  in  communities 
large  enough  to  contain  the  complex  social  problems. 


CHAPTER  IV 

SICKNESS  OR  INJURY— DIRE  ADVERSITY  AND  THE 
TIME  WHEN  SOCIAL  SERVICE  IS  MOST  NEEDED 

IT  is  often  true  that  sickness  or  injury  to  one  member  of 
the  family  becomes  the  first  occasion  for  any  necessity  for 
outside  help,  and,  as  the  hospital  social  worker  is  dealing  with 
the  sick  and  injured,  naturally  her  introduction  to  the  patient 
may  mean  the  beginning  of  some  more  or  less  intensive  social 
work  in  that  home.  Surely  sickness  or  injury  may  prove  to  be 
dire  adversity  in  many  cases,  and  affords  the  opportunity  for 
"the  study  of  character  under  adversity"  which  Dr.  Cabot 
says  is  "the  essence  and  center  of  social  work."  We  have 
often  seen  strong  men  melt  under  the  ravages  of  disease,  and 
express  a  desire  to  see  mother  or  wife  or  sister  to  whom  they 
owe  much,  yet  have  become  estranged  through  a  wandering, 
dissolute  life.  This  is  the  psychologic  moment  to  do  all  that 
is  possible  to  bring  about  a  reconciliation  and  send  the  man 
away  from  the  hospital  with  a  new  determination.  Often 
it  takes  a  severe  shock  to  bring  a  man  to  his  senses,  and  even 
if  he  does  seem  hardened  to  all  good  influences,  or  we  feel  is 
apt  to  retrace  his  steps  afterward,  we  must  make  the  most 
of  our  opportunity,  realizing  that  our  work  at  this  time  is  like 
bread  cast  upon  the  water,  and  we  may  find  it  after  many  days. 
It  is  not  sufficient  to  concentrate  our  efforts  while  he  is  in  the 
hospital;  our  work  is  almost  sure  to  be  a  failure  unless  we  follow 
it  by  putting  him  in  touch  with  an  outside  agency  that  will 
continue  the  good  influences. 

We  recall  one  man  in  whom  we  felt  interested,  and  put  in 
touch  with  the  Y.  M.  C.  A.,  a  settlement  house,  and  a  minister, 
32 


SICKNESS   OR  INJURY  33 

after  he  left  the  hospital,  in  our  effort  to  bring  about  his 
reformation,  obtain  work,  and  secure  some  further  education 
for  him.  He  tried,  and  stumbled  along,  and  fell  and  rose, 
passing  through  the  jail  several  times,  having  delirium  tremens, 
went  to  the  county  house,  returned  to  town,  and  got  into  jail 
again  for  drunkenness.  Finally,  by  the  tactful  handling  and 
good  influence  of  the  minister  who  kept  in  touch  with  him 
through  all  these  vicissitudes  he  straightened  up,  returned  to 
his  wife,  and  obtained  work. 

In  this  case  the  hospital  touch  was  the  social  worker's 
opportunity  to  inaugurate  some  work  which  proved  effective. 
Often  patients  need  a  friend,  only  a  friend,  to  take  an  interest 
at  this  moment  in  their  lives  and  give  them  courage  to  go  on 
after  they  get  well,  to  show  them  that  there  is  some  good  in 
this  world  which  has  seemed  to  use  them  so  roughly. 

There  is  another  class  of  cases,  however,  where  sickness  is 
a  dire  calamity,  and  which  calls  for  the  truest  kind  of  service, 
when  the  breadwinner  of  the  family  or  the  mother  is  stricken 
and  adversity  first  enters  the  home.  They  may  struggle  along 
by  themselves  in  their  endeavor  to  maintain  their  independ- 
ence, but  when  resources  are  exhausted  they  are  obliged  to 
seek  advice  and  help.  The  social  worker  in  the  hospital,  be- 
cause of  her  acquaintance  with  the  medical  side,  foresees  this 
result,  and  starts  her  work  in  time  so  that  the  extremity  may 
not  be  reached.  Or  she  is  in  a  position  to  advise  an  outside 
agency,  already  handling  the  family  problem,  what  the  result 
of  the  illness  or  injury  may  be  or  the  length  of  time  the  patient 
may  be  incapacitated. 

In  case  of  tuberculosis  or  insanity  or  chronic  disease  co- 
operative action  may  be  taken  for  the  patient's  transfer  to  an 
institution,  and  the  care  of  the  family  arranged  for.  In  the 
dispensary,  disease  is  often  discovered  in  its  incipient  stage,  and 
with  prompt,  adequate  treatment,  medical  and  social,  the 

3 


34  "THE  HOSPITAL  AS  A  SOCIAL  AGENT" 

patient  may  be  saved  much  time  and  suffering  and  the  com- 
munity a  danger  and  burden. 

Some  people  are  utterly  unable  to  meet  adversity,  especially 
that  of  sickness,  and  they  need  the  most  careful,  tactful  help 
to  brace  them  up  or  to  press  home  to  them  their  part  of  the 
responsibility.  Sometimes  their  helplessness  is  pitiful;  this  is 
especially  so  with  a  husband  who  is  left  with  the  baby  at  home 
when  his  wife  must  come  to  the  hospital;  he  has  no  idea  what 
to  do.  Also  an  aged  person,  separated  from  the  companion 
of  many  years,  often  seems  as  helpless  as  a  child. 

So  a  most  valuable  opportunity  comes  to  the  worker  in  the 
hospital  to  accomplish  most  effective  social  work  as  well  as  to 
assist  in  bringing  about  most  urgent  medical  or  surgical  care. 
A  mother  who  fears  to  leave  her  child  in  the  hospital  to  have 
an  abscess  opened  may  have  those  fears  overcome  by  the 
friendly  visitation  and  urgent  entreaties  of  the  social  worker, 
and  once  the  mother's  confidence  in  the  hospital  is  gained  by 
successful  results,  it  remains  steadfast.  Here  once  more  is 
demonstrated  the  doctor's  aid  in  treatment  through  the  co- 
operation of  the  social  service  department. 

Hospital  social  workers  have  opportunities  for  service  that 
are  not  accorded  to  others:  first,  because  sickness  or  injury  in- 
capacitates the  individual,  rendering  him  helpless  and  de- 
pendent; second,  because  his  helplessness  makes  him  more  sus- 
ceptible to  good  influences;  third,  because  his  stay  in  the 
hospital  brings  him  under  direct  observation  and  care;  fourth, 
because  most  complex  social  problems  may  develop  from  the 
patient's  illness,  calling  for  intensive  work. 

JAKE,  JOHN,  AND  THE  MISSION  MAN 

In  Fig.  1  are  seen  three  patients  snapped  while  taking  their 
outing  on  the  hospital  lawn,  and  they  represent  three  different 


I  m 


Fig.  1. — Jake,  John,  and  the, 'Mission; mar*.,, 


JAKE,    JOHN,    AND    THE   MISSION   MAN  35 

types  of  cases  to  which  principles  set  forth  in  the  foregoing 
chapter  may  be  applied. 

Jake,  a  Russian  Jew,  had  been  in  the  hospital  a  long  time, 
suffering  from  a  diseased  ankle,  which  had  not  yielded  to  treat- 
ment, and  the  doctor  finally  told  him  his  foot  would  have  to  be 
amputated.  He  had  a  wife  and  several  small  children  at  home, 
and  he  could  see  nothing  but  dependence  for  all  of  them  if  he 
were  deprived  of  his  foot.  He  brooded  over  this  until  he  be- 
came desperate,  and  one  day  secured  a  razor  from  another 
patient  in  the  ward,  went  into  the  toilet,  and  cut  his  throat. 
Fortunately  he  was  found  almost  immediately,  and  hurried 
to  the  operating  room,  where  doctors  were  sewing  the  wounds 
and  inserting  a  tracheotomy  tube  within  twenty  minutes. 
Jake  recovered,  and  soon  realized  what  a  foolish  trick  he  had 
done.  He  was  most  grateful  to  all  who  had  worked  so  hard 
to  save  his  life  that  he  might  have  it  for  his  family.  A  spirit 
of  encouragement  and  cheer  was  thrown  about  Jake  during  his 
convalescence,  and  he  viewed  life  in  a  different  light.  The 
Jewish  Charities  were  called  upon  to  take  up  the  family 
problem,  and,  through  their  interpreter,  they  were  able  to 
assure  him  that  his  wife  and  children  should  not  want  while 
he  was  in  the  hospital.  One  of  the  most  remarkable  parts  of 
this  story  is  that  while  Jake's  neck  was  healing  his  ankle  got 
entirely  well,  and  the  doctor  was  deprived  of  his  amputation 
job.  While  Jake's  own  operation  at  the  other  end  of  the  line 
brought  such  favorable  results,  we  would  not  advise  other 
patients  to  try  it.  Jake  looks  quite  content  sitting  on  the 
bench  with  his  wife  and  child,  and  he  was  indeed  happy  then. 

John,  the  boy  standing  on  crutches,  had  a  tuberculous  knee. 
When  he  came  to  the  hospital  he  was  rescued  from  among  the 
little  "wharf  rats"  that  hung  around  the  boat  landings,  so  he 
needed  much  taming  down  in  conversation  and  in  actions. 
The  effect  of  hospital  discipline  and  kind  treatment  of  hospital 
attaches  was  soon  manifest,  and  John  became  quite  a  respect- 
able and  respectful  boy.  One  time,  after  weeks  of  confine- 
ment, John  borrowed  without  leave  a  pair  of  crutches  from  one 
of  the  other  children  and  disappeared  from  the  ward.  He  was 


36  "THE  HOSPITAL  AS  A  SOCIAL  AGENT" 

discovered  at  home  and  brought  back  by  his  mother.  For 
a  year  he  was  in  and  out  of  the  hospital,  attended  the  dispen- 
sary, and  was  visited  by  the  social  worker  to  keep  him  in  line, 
all  for  the  purpose  of  saving  a  boy  from  being  a  lifelong 
cripple  and  making  something  better  than  a  vagabond  when 
he  grew  up;  indeed,  something  approaching  a  worthy  citizen. 
Both  of  these  were  saved  for  the  home. 

The  Mission  Man  was  one  of  those  single,  unattached  men, 
who  had  been  rescued  by  a  city  mission,  and  who  was  trying  to 
make  amends  for  his  past  useless  life.  But  health  was  gone, 
he  was  suffering  from  a  kidney  trouble  which  incapacitated  him 
for  work  which  would  keep  him  independent,  and  was  destined 
to  become  a  burden  to  someone  somewhere.  This  is  a  type  of 
case  representing  very  little  service  that  can  be  rendered  by 
the  hospital  social  worker,  yet  needing  the  friend  who  will  see 
that  a  clean,  comfortable  place  is  found  for  him  when  the  hos- 
pital can  do  no  more  in  the  way  of  treatment.  It  is  only  a 
question  of  a  permanent  home,  but  that  must  be  managed  in  a 
kind,  friendly  way,  that  the  man  may  not  feel  his  desperately 
dependent  situation.  So  the  Mission  Man  stands  in  the  back- 
ground of  our  picture,  alone  in  the  world  and  dependent  upon 
it;  apart  from  the  other  two,  whom  we  are  endeavoring  to  put 
into  their  places  in  the  world  for  service  to  themselves  and  to 
others. 

THE  "A"  FAMILY 

Italians;  children — boy,  age  eight;  twins,  age  four;  baby, 
age  four  months. 

This  case  illustrates  the  complex  problem  which  may  de- 
velop when  sickness  brings  dire  adversity. 

A  young  Italian  woman  was  referred  to  the  out-patient 
department  by  the  visiting  nurses  because  she  was  in  an  ex- 
tremely nervous  state,  and  unfit  to  care  for  her  children  and 
her  home.  Her  husband  had  died  in  the  hospital  the  previous 
week,  entering  as  a  private  patient,  yet  she  was  so  destitute 
that  she  did  not  have  shoes  to  put  on  to  come  to  the  hospital 
when  summoned  at  the  time  of  his  death.  After  the  doctor 
examined  her  in  the  dispensary  he  thought  it  would  be  best 
to  place  her  on  the  ward  for  observation  and  treatment.  It 


Fig.  2. 


Fig.  3. 
Figs.  2  and  3.— The  "A"  children  in  the  "Home.1 


THE    "A"    FAMILY 


37 


was  hoped  that  rest,  good  food,  and  a  change  of  surroundings 
would  restore  her  nervous  and  mental  equilibrium.  Her 
baby  was  admitted  with  her,  as  she  was  nursing  it.  It  was 
then  necessary  to  make  some  provision  for  the  children,  as 
they  could  not  stay  in  the  house  alone,  nor  were  the  neighbors 
able  to  care  for  them  longer.  They  had  done  much  for  the 
family  the  past  few  months.  The  boy  was  sent  temporarily 
to  the  detention  home,  one  of  the  twins  to  the  children's  home, 
and  the  other  one  to  the  hospital,  as  she  was  not  well.  Through 
some  Italian  neighbors  it  was  learned  that  Mr.  A.  had  been  a 
hard  drinker  and  very  abusive  to  his  wife,  not  providing  the 
necessities  of  life  for  the  family,  and  the  house  was  destitute  of 
furniture.  He  had  threatened  the  life  of  his  wife,  and  she 
lived  in  constant  terror  of  him.  She  was  a  devoted  mother 
and  a  good  home-maker  until  the  brutality  of  her  husband 
divested  their  home  of  all  the  elements  which  make  for  happi- 
ness and  comfort.  Rest  from  care  and  responsibility  did  not 
bring  about  the  improvement  that  was  hoped  for,  she  became 
more  disturbed  mentally,  and  the  doctor  thought  it  was  best 
to  have  her  transferred  to  the  State  Hospital  for  the  Insane. 
The  social  worker  filed  a  petition  for  her  hearing  in  the  probate 
court,  and  the  judge  came  to  the  hospital  to  take  the  testimony 
and  have  commitment  papers  made  out.  The  next  day  she 
was  taken  to  the  State  Hospital.  It  then  became  necessary 
to  make  some  more  permanent  disposition  of  the  children. 
They  were  all  declared  dependent  in  the  juvenile  court  and 
committed  to  the  Children's  Home.  The  social  service  depart- 
ment being  the  only  agency  handling  the  whole  family  problem, 
it  was  agreed  by  the  judge  that  the  children  should  be  held  by 
the  home  until  it  was  determined  whether  or  not  the  mother 
would  recover  so  as  to  be  able  to  return  to  care  for  them,  and 
that  the  social  worker  should  keep  informed  of  her  condition. 
The  superintendent  of  the  State  Hospital  was  made  acquainted 
with  the  social  problem  involved,  and  letters  were  received  at 
intervals  from  him.  No  favorable  report  came  from  her,  but 
she  gradually  grew  worse,  and  died  at  the  hospital  a  year  and 
a  half  after  being  admitted.  As  will  be  seen  by  the  accompany- 
ing pictures  the  children  are  beautiful,  attractive  children,  and 
they  have  displayed  good  traits  during  their  stay  in  the  home, 


38  "THE  HOSPITAL  AS  A  SOCIAL  AGENT" 

so  there  has  been  no  difficulty  in  finding  suitable  homes  for 
them  since  the  mother  died.  After  the  mother  was  removed  to 
the  State  Hospital,  an  Italian  man  who  had  been  a  neighbor 
and  friend,  found  in  a  trunk  at  the  house  two  bank  books,  one 
belonging  to  Mr.  A.,  showing  a  balance  on  deposit  of  $200  and 
over;  the  other  one,  Mrs.  A.'s,  with  the  last  item  a  balance 
checked  over  to  her  husband.  This  is  only  one  link  in  the  sad 
story  of  this  little  woman  whose  life  was  wrecked  by  the 
brutality  of  the  man  she  had  bound  herself  to. 

ELIZABETH 

The  following  case  demonstrates  the  hospital  social  work- 
er's opportunity  for  service. 

^  March  28/14.  Patient  was  brought  to  the  hospital  about 
midnight  in  an  intoxicated  condition,  having  cut  her  arm  on 
a  beer  bottle,  severing  the  flexor  tendon  and  ulnar  nerve, 
and  bleeding  profusely.  She  remained  in  a  drunken  stupor 
the  following  day. 

March  30th.  Interviewed  patient.  Find  that  she  is  a 
domestic  in  the  employ  of  Mrs.  O.;  has  been  there  one  year; 
earns  $4.00  a  week.  Her  parents  live  in  a  suburb  of  the  city, 
and  she  thinks  she  can  return  to  Mrs.  O.  's  when  she  leaves  the 
hospital. 

Later:  Interviewed  Mrs.  O.  when  she  came  to  the  hospital 
to  see  Elizabeth.  She  says  that  the  patient  cannot  return  to 
her  house.  She  is  a  bad  girl,  immoral  and  dissipated.  Mrs.  O. 
has  allowed  her  to  remain,  thinking  she  might  be  able  to  do  her 
some  good,  but  there  are  small  children  in  the  family  and  she 
cannot  run  the  risk  of  her  influence  with  them.  Mrs.  O.  states 
that  on  the  night  of  the  accident  Elizabeth  was  out  with  a 
married  man  in  company  with  others  of  the  same  sort.  They 
were  all  drinking,  and  when  well  under  the  influence  of  liquor, 
as  they  walked  along  the  street,  she  stumbled  and  fell,  breaking 
a  beer  bottle  which  she  was  carrying,  and  made  the  ugly  wound 
she  had.  She  was  first  taken  to  her  home,  and  her  people  sent 
her  with  the  man  to  Mrs.  O's.  The  latter  saw  that  Elizabeth 


ELIZABETH  39 

needed  medical  attention  at  once,  and  she  insisted  upon  the 
man's  taking  her  to  the  hospital.  Mrs.  O.  says  the  wife  of  the 
man  is  very  angry  with  Elizabeth,  and  if  she  is  allowed  to 
come  to  the  hospital  to  see  her  a  disturbance  will  be  created. 
The  woman  will  be  barred  from  visiting  the  patient. 

Mrs.  O.  asks  if  this  case  might  not  be  taken  up  with  the 
proper  authorities,  to  place  the  girl  where  she  will  not  be  a 
menace  to  the  community,  as  she  feels  that  she  is  either  de- 
fective or  delinquent.  The  social  worker  promises  to  talk 
with  the  probate  judge,  and  see  if  there  is  not  some  State 
institution  where  she  may  be  committed. 

March  31st.  Called  upon  the  judge,  and  stated  the  case 
to  him.  He  says  there  is  no  State  institution  that  will  take 
her,  and  he  is  unable  to  do  anything  unless  she  can  be  adjudged 
insane.  He  advised  seeing  the  chief  of  police.  Called  upon 
the  chief,  and  he  stated  that  the  girl  had  violated  no  laws  and 
there  was  no  cause  for  her  arrest. 

April  1st.  Through  the  C.  O.  S.  found  that  Mr.  B.,  who 
conducts  a  mission  in  the  neighborhood  where  her  parents 
live,  knows  Elizabeth  very  well,  and  also  knows  the  lack  of 
sympathy  and  help  in  the  home.  He  was  called  and  came  to 
see  her  at  the  hospital.  He  found  her  quite  penitent  and  ready 
to  promise  that  she  will  lead  a  different  life  when  she  leaves  the 
hospital.  The  outcome  of  the  case  is  as  follows:  Mr.  B. 
talked  with  the  family,  pointing  out  their  duty  toward  the 
girl  at  this  time,  and  told  them  she  could  turn  over  a  new  leaf 
if  they  would  give  her  their  support.  He  asked  their  co-opera- 
tion in  his  efforts  to  place  her  in  surroundings  that  would  help 
to  uplift  as  soon  as  she  was  discharged  from  the  hospital.  A 
sister  who  lived  just  outside  of  town  offered  her  a  home  until 
she  was  entirely  recovered,  and  then  Mr.  B.  found  her  a  place 
to  work  in  a  family  where  she  would  be  kindly  treated  and 
helped  in  the  upward  road.  Although  it  is  three  years  since 
the  accident,  she  has  not  retraced  her  steps,  but  has  gone 
steadily  on  in  the  better  life.  She  is  now  a  respected  member 
of  the  community  in  which  she  lives,  active  in  the  little  church, 
and  is  planning  to  marry  a  man  who  has  passed  through 
much  the  same  change  that  she  has. 


CHAPTER  V 

SERVICE  TO  THE  INDIVIDUAL,  TO  THE  COMMUN- 
ITY, AND  TO  SOCIETY 

1.  THE  TUBERCULOUS  PATIENT. 

2.  THE  EPILEPTIC,  INSANE,  AND  FEEBLEMINDED  PATIENT. 

3.  THE  PROBLEM  OF  THE  UNMARRIED  MOTHER. 

MUCH  stress  is  laid  on  the  responsibility  of  social  workers 
in  their  service  to  the  individual,  to  the  community,  and  to 
society;  this  is  the  tripod  of  efficient  work.  Each  foot  of  the 
tripod  is  equally  important,  as  each  carries  an  equal  share  of 
the  whole  burden  of  humanity's  welfare.  Work  accomplished 
in  one  direction  is  a  benefit  to  the  whole  because  of  the  close 
interrelation.  The  relation  of  the  individual  to  the  com- 
munity and  to  society,  and  the  maladjustment  of  this  rela- 
tionship through  the  reactionary  influences,  is  the  cause  of  the 
many  and  varied  social  problems. 

One  cannot  live  wholly  apart  from  society,  as  is  well  illus- 
trated by  the  life  of  a  hermit,  who,  after  years  of  separation,  is 
suddenly  thrust  upon  the  community  by  means  of  sickness, 
accident,  or  death  as  a  real  social  problem.  The  kind  of  life 
an  individual  lives  has  its  influence  upon  society,  and  con- 
versely the  good  or  bad  in  society  affects  the  life  of  each  indi- 
vidual member.  Each  person  is  a  part  of  the  community  and 
of  society,  with  his  responsibilities  and  moral  obligations,  and 
the  members  of  society,  as  a  whole,  are  deeply  responsible  for 
the  influences  which  surround  the  individual.  We  are  "our 
brother's  keeper,"  and  we  cannot  escape  this  responsibility. 
It  is  not  necessary  for  us  to  engage  actively  in  service  to  fulfil 


THE   TUBERCULOUS   PATIENT  41 

our  obligations;  our  habits  and  every-day  actions  speak  to  the 
world  for  good  or  evil.  The  solitary  life  of  the  recluse  has  its 
influence  as  truly  as  that  of  the  man  who  figures  prominently 
in  the  courts. 

So  the  life  of  the  individual  ramifies  into  the  life  of  the 
community,  making  the  warp  and  woof  of  society,  and,  like 
the  finished  cloth,  the  texture  exhibits  the  quality  of  the 
threads  which  are  woven  into  the  fabric.  As  members  of 
society,  then,  we  are  gravely  responsible  for  each  individual, 
both  personally  and  in  so  far  as  we  allow  conditions  to  exist 
which  are  deleterious  to  the  life  of  the  community. 

Social  workers  should  keep  in  mind  this  tripod  of  efficiency 
as  their  standard  and  base  their  case  work  upon  it.  Do  not 
follow  out  the  lines  of  least  resistance  or  dispose  of  a  case  in 
the  quickest  way,  as  this  habit  tends  to  narrow  one's  ability 
to  do  effective  work,  or  else  it  leads  to  a  desire  for  numbers 
rather  than  efficiency,  and  social  work  can  never  be  estimated 
in  numbers. 

This  threefold  responsibility  is  demonstrated  in  the  three 
classes  of  cases  with  which  the  hospital  social  worker  comes 
in  contact:  the  tuberculous  patient,  the  epileptic,  insane  and 
feebleminded,  and  the  unmarried  mother. 

1.  THE  TUBERCULOUS  PATIENT 

From  the  standpoint  of  sickness,  physical  suffering,  and 
death  there  is  probably  no  other  medicosocial  problem  that 
carries  with  it  into  the  community  more  serious  results,  and 
consequently  calls  for  more  intensive  work,  than  that  of  the 
tuberculous  patient.  Further,  with  the  exception  of  the  vene- 
real problem,  no  other  presents  such  difficulties  in  the  way  of 
solution.  Recognizing  as  we  do  that  both  tuberculosis  and 
venereal  diseases  are  preventable,  we  realize  that  medical 
treatment,  prophylactic  measures,  education,  and  social  re- 


42  THE  HOSPITAL  AS  A  SOCIAL  AGENT" 

adjustment  are  the  factors  which  make  up  the  armed  force  to 
combat  these  diseases.  The  tuberculosis  problem  has  made 
gratifying  headway  in  spite  of  its  enormity,  yet  it  is  far  from 
being  solved.  The  results  of  this  disease  are  so  apparent,  so 
open;  its  spread,  its  suffering  and  death  so  appalling,  that  the 
whole  mass  of  people  have  been  made  aware  of  its  dangers 
and  have  readily  enlisted  in  the  fight  against  it.  The  diffi- 
culties in  the  way  of  an  adequate  solution  of  the  venereal 
problem  are  more  insurmountable  because  of  a  more  or  less 
marked  secrecy  which  is  maintained  by  persons  afflicted  with 
syphilis  or  gonorrhea,  and  because  it  is  so  acutely  involved 
with  the  evil  which  is  responsible  for  its  existence  in  the  com- 
munity. It  is  only  in  recent  years  that  publicity  has  laid  bare 
the  real  facts  regarding  the  extent  of  venereal  disease  and  its 
awful  consequences.  People  are  only  beginning  to  be  educated 
in  this  direction,  and  there  can  be  no  successful  campaign 
inaugurated  without  first  a  universal  plan  of  education.  The 
enormity  of  the  problem  and  the  huge  difficulties  in  the  way 
have  not  yet  ceased  to  stagger  workers  and  inhibit  their 
activities,  for  at  every  turn  an  insurmountable  wall  looms 
up  before  them.  In  setting  aside  this  problem  for  that  of  the 
tuberculous  patient  we  do  not  regard  its  dangers  as  less,  but 
the  present  outlook  for  the  great  white  plague  as  more  nearly 
ripe  for  substantial  results. 

Whatever  the  community's  facilities  are  for  caring  for 
tuberculosis,  the  social  worker  should  keep  in  mind  the  prin- 
ciples which  govern  the  treatment  of  the  disease  and  the  ele- 
ments which  make  up  the  danger  to  others.  Very  few  com- 
munities are  prepared  to  meet  in  an  adequate  way  the  needs 
of  this  problem,  cases  are  not  discovered  until  they  are  too 
far  advanced,  patients  are  dying  in  the  homes  and  infecting 
other  members  of  the  family;  hospital  and  sanatorium  facili- 
ties for  the  care  of  incipient  cases  are  unequal  to  the  demand, 


THE   TUBERCULOUS   PATIENT  43 

and  our  hands  are  so  far  tied.  However,  we  know  that  a  be- 
ginning case  has  every  chance  to  recover  if  he  can  have  fresh 
air  day  and  night  in  abundance,  good,  nourishing  food,  mod- 
erate exercise,  and  cheerful  surroundings.  He  must  use  cer- 
tain precautions  for  his  own  sake  and  for  the  sake  of  others 
in  the  family.  This  routine  intelligently  carried  out,  and 
the  patient  kept  under  supervision  of  a  physician,  either 
private  or  dispensary,  may  bring  about  very  satisfactory 
results  in  the  home  without  removing  him  to  a  sanatorium. 

We  recall  the  case  of  a  young  boy,  fifteen  years  old,  whose 
treatment  was  supervised  from  the  dispensary.  Someone 
interested  in  him  provided  a  tent  which  was  pitched  in  his 
own  yard,  where  he  slept  even  in  the  coldest  weather.  One 
night  the  wind  blew  the  tent  over,  but  he  set  it  up  again  and 
continued  sleeping  there,  for  he  knew  it  meant  life  to  him. 
.A  little  nephew  in  his  home  attended  kindergarten,  and  he 
took  him  each  day  to  and  from  the  school,  thus  getting  a 
proper  amount  of  exercise  outdoors.  Then  he  secured  a  few 
pigeons  and  built  a  house  for  them,  and  this  afforded  occu- 
pation for  him.  Returning  regularly  to  the  dispensary  he 
was  weighed  each  time,  gaining  steadily,  and  improving  in 
every  way.  The  following  summer  he  went  to  the  country, 
where  he  was  doing  well  at  last  accounts. 

After  the  fresh-air  treatment  was  accepted  as  curative, 
and  before  special  sanatoria  were  built,  tents  were  pitched 
in  yards,  porches  were  enclosed  with  screens,  beds  were  put 
on  the  roofs,  windows  were  extended,  any  outdoor  corner 
was  arranged  for  the  patient  to  sleep,  and  even  in  the  crowded 
cities  good  results  were  obtained.  Reference  to  some  of  the 
early  reports  of  social  service  work  in  hospitals  will  show  how 
extensively  this  was  carried  out  and  what  the  results  were. 
In  these  later  days,  since  special  institutions  have  become 
more  abundant,  we  have  too  easily  fallen  into  the  habit  of 


44  "  THE  HOSPITAL  AS  A  SOCIAL  AGENT  " 

thought  that  all  cases  must  be  removed  from  the  home  to  a 
sanatorium  for  effective  treatment.  The  facts  are,  institu- 
tions are  always  full,  and  the  number  of  beds  available  falls 
far  short  of  meeting  the  demands,  and  it  behooves  social 
workers  to  save  these  places  for  patients  who  cannot  be  cared 
for  successfully  at  home,  or  where  they  are  a  danger  to  young 
persons  or  children  in  the  family.  There  may  be  other  social 
reasons  why  the  home  cannot  be  utilized;  all  these  should  be 
taken  into  consideration  before  deciding  where  and  how  the 
patient  should  receive  the  treatment.  One  advantage  to  be 
gained  from  the  sanatorium  care  is  the  training  which  patients 
receive  in  prophylaxis,  and  if  there  is  a  degree  of  intelligence 
to  grasp  this,  much  good  is  done  in  the  way  of  education. 

If  it  is  possible  to  establish  in  connection  with  the  tuber- 
culosis clinic  a  broad,  comprehensive  program,  such  as  has 
been  followed  out  in  Bellevue  Hospital,  New  York,  the  re- 
sults will  be  found  much  more  satisfactory.  The  dispensary 
should  be  made  the  examining  agent  at  least,  and  the  dis- 
ease may  thus  be  detected  in  its  beginning  stage  when  proper 
treatment  can  be  inaugurated.  Or,  if  cases  are  advanced, 
they  may  be  placed  where  they  will  not  be  a  danger  to  others. 
Again,  having  access  to  all  the  special  clinics  and  the  laboratory, 
#-ray,  and  hospital  wards,  there  is  opportunity  for  careful 
diagnosis  and  treatment  of  complications. 

The  educational  phase  of  the  work  with  tuberculous 
patients  has  not  been  developed  in  dispensaries  as  extensively 
as  it  should  be.  The  chief  reason  is  the  lack  of  a  sufficient 
force  of  social  workers  to  carry  out  such  a  plan.  But  it  is  a 
most  important  measure  in  the  fight,  as  it  is  possible  to  reach 
in  groups  those  who  are  the  carriers  of  infection,  and  so  to  dis- 
seminate the  knowledge  of  prevention  from  a  most  impressive 
source.  Classes  for  instruction  upon  the  principles  of  the 
treatment,  upon  the  technic  of  precautionary  measures, 


THE   EPILEPTIC,    INSANE,    AND    FEEBLEMINDED   PATIENT      45 

upon  the  importance  of  cheer  and  hope,  and  the  teaching 
by  graphic  posters  the  many  sources  of  danger;  these  are 
features  of  the  educational  work.  This  important  aid  in  pub- 
lic health  work  will  be  spoken  of  in  another  chapter.  It  is 
only  necessary  to  visit  the  special  tuberculosis  clinics  where 
intensive,  well-organized  work  is  carried  on  to  be  convinced 
of  the  opportunities  for  most  effective  service.  Our  plea  is 
for  its  introduction  into  the  smaller  dispensaries  where  re- 
sults differ  only  in  degree. 

2.  THE  EPILEPTIC,  INSANE,  AND  FEEBLEMINDED  PATIENT 

One  of  the  greatest  responsibilities  of  social  workers  to 
the  individual,  the  community,  and  society  is  the  disposition 
into  proper  channels  of  mental  defectives.  It  would  seem  as 
though  this  were  so  self-evident  a  fact  that  there  need  not  be 
much  said,  and  this  is  true  where  the  condition  of  the  patient 
is  so  dangerous  that  immediate  steps  must  be  taken  to  safe- 
guard all  concerned,  but  with  the  milder  types  of  defectives 
there  is  a  tendency  to  leniency  when  the  question  of  cus- 
todial care  arises.  It  is  a  well-established  truth  that  all  mental 
defectives  are  a  menace  to  society  unless  they  can  be  guarded 
and  controlled,  if  not  in  the  home,  then  in  an  institution. 
The  detection  of  the  milder  types  of  mental  disorder  is,  there- 
fore, most  important,  and  this  may  be  more  easily  done  in  the 
hospital  and  dispensary,  as  patients  are  under  more  constant 
observation  than  otherwise.  It  is  sometimes  difficult  to  dif- 
ferentiate closely  enough  between  insanity,  feeblemindedness, 
and  epilepsy  to  decide  which  is  the  proper  institution  for  the 
patient.  Where  a  psychopathic  ward  is  available  in  the  com- 
munity it  serves  as  a  clearing-house  and  should  be  used  as  such, 
entrance  to  a  State  institution  being  more  easily  secured 
through  its  specialists. 

In  justice  to  society,  the  mental  defective  should  have 


46  "  THE  HOSPITAL  AS  A  SOCIAL  AGENT  " 

proper  attention;  those  who  are  in  condition  to  be  a  menace, 
or  whose  home  surroundings  are  unfit  for  adequate  super- 
visory care,  should  be  placed  in  an  institution,  and  those 
who  are  amenable  to  medical  treatment  should  be  given 
every  opportunity  for  readjustment  and  improvement. 
Clinics  for  nervous  and  borderline  mental  cases  are  of  won- 
derful value  in  the  community,  especially  when  the  doctor's 
work  is  supplemented  by  that  of  a  social  service  nurse  who 
investigates  the  home  conditions  and  surroundings,  and  helps 
in  the  patient's  readjustment  in  the  home. 

The  work  which  is  being  done  by  a  number  of  the  States 
through  a  well  organized  mental  hygiene  society  or  committee 
is  keeping  many  a  mental  case  out  of  the  State  Hospital,  and 
helping  many  more  to  return  to  their  homes  and  remain  well 
because  of  the  efficient  social  service  rendered.  These  societies 
have  been  the  means  of  establishing  mental  clinics  attended 
by  specialists,  and  of  placing  there  a  nurse  with  experience 
in  mental  diseases  to  visit  the  home  and  learn  the  contribut- 
ing causes  of  the  breakdown.  If  there  are  readjustments 
either  in  the  home  or  with  the  patient,  the  nurse  may  render 
very  valuable  assistance.  These  clinics  sift  out  the  cases  that 
are  amenable  to  treatment  from  those  which  are  a  positive 
menace  to  society  and  make  possible  adequate  medical  or 
social  care.  What  a  service  to  the  individual  and  to  the  com- 
munity when  people  are  thus  returned  to  their  place  in  the 
life  and  work  of  the  world! 

On  the  general  hospital  wards  there  will  be  found  the 
occasional  case  of  insanity  following  a  fractured  skull,  or  a 
postoperative  mental  disturbance,  or  a  case  of  paretic  demen- 
tia, where  the  physical  symptoms  have  been  of  such  a  nature 
that  mental  symptoms  were  obscured  or  unnoticed  until  the 
patient  was  under  more  close  observation  in  the  hospital. 
The  epileptic  insane  drift  into  the  hospital  as  emergency 


THE   PROBLEM   OF   THE   UNMARRIED   MOTHER  47 

cases,  and  the  wandering  types  of  insanity  find  their  way  there 
because  they  can  so  readily  assume  physical  illness.  Cases 
of  hysteria  prove  to  be  a  great  deal  of  trouble  and  annoyance 
on  the  wards,  and  are  sometimes  hard  to  get  rid  of,  as  they 
develop  some  very  convenient  and  seemingly  serious  symptoms 
when  told  they  may  be  discharged. 

The  social  worker  has  a  definite  responsibility  with  these 
patients,  and  should  not  allow  them  to  be  sent  out  into  the 
community  without  at  least  making  an  effort  to  place  them 
in  the  right  channels.  It  is  often  difficult  or  impossible  to 
carry  out  adequate  plans,  owing  to  opposition  by  patient  or 
friends  which  cannot  be  overcome,  but  the  worker  has  not 
done  her  full  duty  until  she  has  made  every  possible  effort 
to  serve  the  individual  and  the  community  in  an  adequate 
way.  The  responsibility  goes  back  of  the  social  worker  to  the 
hospital  physician,  upon  whose  medical  opinion  the  social  work 
must  be  based.  It  is  a  true  but  unfortunate  fact  that  gen- 
eral practitioners,  many  of  them,  neither  recognize  the  mild 
types  of  mental  disorder  nor  the  real  import  of  the  social 
problem  involved;  they  are  more  or  less  indifferent  to  the 
danger  of  the  presence  of  these  patients  in  society.  We  can- 
not help  feeling,  however,  that  these  same  doctors  may  be 
educated  to  a  realization  of  the  importance  of  this  question 
by  the  tactful  efforts  of  the  social  worker.  Her  responsibility 
is,  therefore,  twofold,  but  we  believe  she  is  equal  to  it  if  she 
can  be  awakened  to  its  importance. 

3.  THE  PROBLEM  OF  THE  UNMARRIED  MOTHER 
The  unmarried  mother  who  finds  herself  in  the  hospital 
is  introduced  to  the  social  worker  at  the  crucial  time  when 
her  problem  becomes  a  vivid  reality,  and  she  must  decide 
which  course  she  will  take,  whether  she  will  follow  the  path 
of  duty  or  her  own  inclination  to  cover  up  one  sin  with  another. 


48  "  THE  HOSPITAL  AS  A  SOCIAL  AGENT  " 

It  is  a  crucial  time  also,  because  the  mother  instincts  are  most 
delicate  and  keen,  and  may  be  nurtured  into  maturity  to 
help  the  mother  in  her  decision  for  the  right.  Unless  the  girl 
is  wholly  unfit  physically,  mentally,  or  morally  to  rear  her 
child,  the  mother  and  baby  should  not  be  separated;  this  is 
the  rule  from  which  we  should  not  deviate  except  under  ex- 
tenuating circumstances.  All  the  influences  should  be  focused 
at  this  time  upon  this  one  course,  nurses  and  doctors  insisting 
upon  her  nursing  the  baby,  and  social  worker  encouraging 
her  in  her  duty  and  securing  assistance  to  help  her  carry  it 
out.  It  almost  always  appears  to  the  girl  that  it  is  impossible 
to  follow  out  the  plan  suggested,  and  she  has  previously  made 
up  her  mind  that  the  only  thing  to  do  is  to  give  the  baby  away, 
because  she  does  not  wish  to  face  the  disgrace  before  the  world, 
and  because  she  thinks  she  cannot  care  for  her  baby  and  at 
the  same  time  support  both.  Then  the  family,  if  they  are 
aware  of  the  circumstances,  prefer  the  "cover-up"  method 
in  their  effort  to  save  the  girl's  disgrace  and  that  of  the  family. 
They  do  not  realize  that  "murder  will  out,"  and  when  it  does, 
it  brings  much  more  disgrace  because  the  double  sin  is  now 
trebled. 

The  girl  should  be  impressed  with  two  things,  namely, 
that  she  is  not  altogether  blameless  in  this  situation,  so  is 
responsible  for  her  part  in  the  care  of  the  baby,  and  that  it  is 
possible  for  her  to  take  care  of  her  baby  and  support  both. 
The  mother's  duty  is  to  follow  nature's  own  way  of  nourishing 
her  offspring,  nurturing  and  giving  to  it  the  best  she  has,  in 
order  to  establish  a  physical  foundation  which  will  insure  a 
strong  child,  able  to  meet  life  as  he  should.  The  first  weeks 
and  months  of  the  life  of  a  babe  are  critical  ones;  if  he  can  be 
safely  carried  through  these  he  has  a  better  chance  in  life 
than  if  he  is  deprived  of  his  mother's  care.  This  in  itself 
should  be  sufficient  argument  to  make  the  girl  decide  to  keep 


THE   PROBLEM   OF   THE   UNMARRIED   MOTHER  49 

her  child  no  matter  what  it  costs  her.  The  charge  of  child 
abandonment  is  a  serious  one  for  a  girl  to  face,  much  more 
serious  than  the  lesser  disgrace  which  she  thinks  she  cannot 
face  before  the  world,  and  rescue  homes  of  all  kinds  and  de- 
nominations are  refusing  to  separate  mother  and  babe  because 
they  realize  the  serious  results  to  both  from  this  procedure. 
The  girl  is  responsible  for  the  life  of  the  child,  and  she  should 
be  deeply  impressed  with  this  fact  from  the  first.  At  the  same 
time,  her  mother  instincts  must  be  appealed  to,  and  the  joys 
and  blessings  which  are  sure  to  come  from  association  with 
the  child,  as  well  as  the  satisfaction  which  results  from  duty 
fulfilled,  should  be  earnestly  set  forth.  Say  to  her,  "How 
can  you  give  up  your  baby,  your  own  flesh  and  blood?  How 
can  you  throw  your  innocent  child  upon  the  world  to  face 
the  disgrace  that  you  wish  to  avoid?  How  can  you  deprive  him 
of  both  father  and  mother?"  Show  her  that  her  friends  and 
the  world  in  general  will  respect  her  more  for  holding  to  her 
duty,  and  that  she  will  be  happier  for  doing  it. 

The  following  letter,  written  by  a  girl  seven  months  after 
her  baby  was  born  in  the  hospital,  shows  the  result  of  this 
course  pursued. 

"DEAR  FRIEND:  Your  welcome  letter  was  received  some 
time  ago,  and  I  wish  I  could  tell  you  what  a  bracer  it  was. 
I  have  not  worked  for  two  weeks;  have  been  very  sick  with 
grip.  I  still  have  a  very  bad  cough.  The  doctor  was  here 
twice  and  I  went  to  his  office  once,  then  I  caught  more  cold. 
Baby  Helen  is  quite  well  just  now,  with  the  exception  of  two 
sore  fingers,  Mamma  says  comes  from  her  teeth,  although  I 
have  seen  no  signs  of  a  tooth  yet.  She  is  getting  so  noisy  now. 
I  do  not  know  what  I  would  do  without  her  now,  as  my  whole 
life  seems  to  be  wrapped  up  in  her.  I  never  realized  I  could 
love  a  little  baby  so  much.  Without  her  I  do  not  know  what 
I  would  do,  for  when  I  get  tired  or  downhearted  and  stop  to 
think  of  her,  I  take  up  my  burden  with  renewed  energy,  and 


50  "  THE  HOSPITAL  AS  A  SOCIAL  AGENT  " 

then  it  is  a  comfort  to  me  to  know  that  I  am  not  the  only  one 
who  is  traveling  this  same  road.  I  get  a  letter  from  a  girl 
friend  of  mine  in  the  city  every  now  and  then  that  always 
gives  me  the  blues,  she  is  always  telling  me  what  the  other 
girls  are  saying,  so  I  wrote  her  not  to  write  any  more.  The 
girls  who  were  true  friends  of  mine  I  still  have  and  the  others 
I  don't  want.  Her  letters  did  me  more  harm  than  good. 
Well  I  will  have  to  close  now.  Write  again  soon  for  I  can 
hardly  wait  till  I  get  your  letters  open  to  read  them.  Trusting 
you  always,  your  friend." 

The  morning  after  her  baby  came  the  social  worker,  talking 
with  her,  asked  her  what  she  planned  to  do.  As  was  expected, 
she  said  she  thought  she  would  have  to  put  the  baby  some- 
where and  go  to  work,  that  she  did  not  want  her  parents  to 
know  of  her  trouble,  for  they  were  not  able  to  help  her,  and 
she  knew  her  father  would  be  very  angry  with  her.  Her 
duty  to  the  baby  and  the  possibility  of  getting  work  in  a 
private  home  when  she  was  strong  enough  was  presented  to 
her  as  a  better  plan,  and  she  was  left  to  think  it  over.  When 
the  worker  visited  the  ward  on  the  following  morning  she 
was  greeted  with  a  bright  smile  from  this  girl,  and  her  first 
words  were,  "I  have  been  thinking  about  what  you  said  yes- 
terday, and  I  have  decided  to  take  your  advice."  Such  good 
news  was  most  gratifying,  and  immediately  the  social  worker 
began  to  plan  for  the  consummation  of  this  purpose.  Corres- 
pondence with  her  mother  living  in  a  nearby  town  was  be- 
gun, the  girl's  pastor  was  called,  and  his  interest  and  help 
solicited.  He  knew  the  relatives  in  town  and  got  in  touch 
with  them.  They  came  to  the  hospital  to  see  her,  and  an  uncle 
offered  her  shelter  until  she  was  strong  enough  to  work. 
The  visitor  from  the  Associated  Charities  called  to  talk  about 
a  suitable  place  for  her  to  work  where  she  could  have  her 
baby.  When  she  left  the  hospital  she  went  to  her  uncle's 
for  two  weeks,  then  a  good  place  was  found  in  a  home  where 


THE   PROBLEM    OF    THE   UNMARRIED   MOTHER  51 

there  was  an  invalid  wife.  The  family  became  very  fond  of 
the  baby,  and  they  appreciated  the  good  work  done  by  the 
girl;  'the  baby  kept  well  and  was  devotedly  loved  by  the 
mother.  Upon  the  death  of  the  wife  in  the  home  it  became 
necessary  to  find  another  place,  but  the  girl  faithfully  and 
contentedly  stuck  to  her  duty.  In  the  fall  it  seemed  best  for 
her  to  go  to  her  own  home,  where  her  mother  and  father  re- 
ceived her  with  open  arms,  and  soon  the  baby  won  her  way 
into  the  hearts  of  all  the  family  so  they  would  not  let  her  go. 
This  girl  is  experiencing  the  joy  and  satisfaction  of  duty  done, 
her  compensation  is  the  bond  of  love  between  herself  and  the 
child,  which  is  strengthening  every  day,  and  she  is  happy 
when  she  looks  at  Baby  Helen,  to  think  she  did  not  cast  the 
innocent  one  upon  the  world  to  fight  her  battle  alone. 

Regarding  the  father  of  the  child,  with  him  the  hospital 
social  worker  has  little  to  do,  her  problem  is  the  immediate 
question  of  the  care  of  the  mother  and  babe,  and  making 
provision  for  them  when  they  leave  the  hospital,  and  she  has 
her  hands  full  if  she  accomplishes  this  successfully.  But  he 
should  not  be  disregarded  altogether,  as  he  is  a  guilty  party 
in  the  situation,  and  has  his  share  of  the  burden  which  he 
should  be  made  to  carry  if  it  is  possible  to  bring  him  to  it. 
If  marriage  is  a  reasonable  solution  at  all,  this  is  the  best 
advice  to  give;  if  not,  some  means  should  be  sought  to  find 
him  and  secure  support  for  the  mother  and  child.  This  is  a 
matter  for  personal  consideration,  as  marriage  might  be  the 
most  disastrous  thing  to  all  concerned,  and  the  publicity 
to  which  a  girl  is  subjected  by  bringing  the  man  into  court  is 
sometimes  more  harmful  than  beneficial.  This  whole  question 
of  the  man  in  the  case  is  best  turned  over  by  the  hospital 
worker  to  an  outside  agency,  as  it  is  usually  involved,  and 
calls  for  follow-up  work  for  some  time. 

The  province  of  the  hospital  social  worker  is  to  start 


52        "  THE  HOSPITAL  AS  A  SOCIAL  AGENT  " 

things  moving  in  the  right  direction,  to  put  the  case  in  the 
right  channel  to  accomplish  just  service  to  the  individual, 
to  the  community,  and  to  society.  Whether  this  is  brought 
about  by  marriage,  by  return  to  the  home  by  reconciliation 
with  the  family,  by  placing  out  in  a  private  home,  or  by  sending 
the  mother  and  babe  to  a  rescue  home  for  the  usual  allotted 
time,  must  be  determined  by  circumstances.  In  the  case  of  an 
irresponsible  girl  or  woman,  especially  if  it  is  her  second  offence, 
it  may  be  best  to  separate  mother  and  babe,  placing  the  mother 
in  a  proper  custodial  institution  and  the  baby  in  the  hands  of 
a  child-placing  agency.  Each  case  must  be  decided  upon  its 
own  merits,  as  it  rests  on  our  tripod  of  efficient  service. 

Two  rather  unusual  cases  of  unmarried  mothers  may  be 
cited  here. 

FOURTEEN-YEAR-OLD  JANE 

Jane  was  admitted  to  the  maternity  ward  of  the  hospital  a 
few  days  before  she  was  to  be  confined,  and  the  social  worker 
became  acquainted  with  her  at  this  time.  She  was  but  four- 
teen years  old,  a  mere  child.  Her  attitude  was  that  of  in- 
difference to  the  situation  which  she  was  facing,  she  seemed  to 
feel  that  it  would  be  an  easy  matter  to  get  rid  of  the  baby  and 
return  home  again  as  free  as  before.  Her  parents  were  re- 
spectable people,  entirely  out  of  the  dependent  class,  but  at 
this  time  needing  the  most  tactful  assistance  in  the  social 
problem  they  were  going  to  be  obliged  to  meet  and  solve. 
When  the  mother  came  to  see  the  girl  the  social  worker  talked 
with  her,  and  found  much  the  same  feeling  that  the  girl  pos- 
sessed. She  stated  that  her  husband  must  not  become  ac- 
quainted with  Jane's  real  condition,  for  he  was  a  very  high- 
tempered  man,  and  she  feared  what  his  anger  would  lead  him 
to  do.  She  knew  the  truth  would  entirely  upset  him.  The 
girl's  duty  in  the  matter  was  presented  plainly  to  the  mother, 
and  she  was  urged  to  help  follow  out  the  right  course,  going  to 
her  husband,  and  telling  him  frankly  of  the  trouble.  Their 
effort  to  keep  the  real  facts  from  their  friends  would  be  futile, 
and  it  was  better  to  face  the  situation  in  an  open,  just  way, 


FOURTEEN- YEAR   OLD   JANE  53 

giving  their  daughter  the  support  she  needed  now  more  than 
ever  before.  The  mother  claimed  that  she  had  tried  to  watch 
Jane  in  every  way  to  prevent  trouble  of  this  kind,  and  she  did 
not  understand  how  it  could  have  come  about.  The  first  day 
of  her  interview  with  the  social  worker  she  went  away  in  tears, 
but  the  next  day  returned  with  smiles,  for  she  had  told  her 
husband,  and  the  storm  that  she  expected  did  not  come. 
They  were  willing  to  follow  the  advice  given,  and  stood  ready 
to  help  in  any  way  they  could.  Jane's  father  called  on  the 
social  worker  to  talk  over  the  plans,  and  broke  down  with 
emotion  during  the  conversation.  It  was  suggested  that  Jane 
go  out  of  the  city  with  her  baby  when  she  was  ready  to  leave 
the  hospital  and  stay  at  a  refuge  home,  where  she  would  learn 
to  care  for  her  baby  and  to  do  many  of  the  things  which  are 
necessary  in  the  home.  This  was  agreed  to,  and  the  transfer 
was  successfully  made.  In  the  course  of  the  investigation 
the  boy  who  was  responsible  was  found,  though,  much  to  our 
surprise,  it  was  difficult  to  attach  the  right  one.  According  to 
his  statements  he  was  not  the  only  boy  who  might  be  impli- 
cated. He  belonged  to  a  good  family,  and  his  father  had  a 
prosperous  business,  in  which  his  son,  then  seventeen  years  of 
age,  was  receiving  training  for  his  life-work.  The  boy  at 
once  expressed  a  willingness  to  do  the  right  thing  by  Jane,  and 
his  parents  also  took  a  most  sensible  view  of  the  situation  and 
promised  support.  A  most  unique  situation  thus  existed, 
where  the  parents  on  both  sides  stood  ready  to  help,  and  by 
coming  together  and  talking  things  over  they  agreed  upon  the 
best  plan  for  both  the  boy  and  girl.  On  account  of  their 
youth  they  were  neither  of  them  mature  enough  to  establish 
and  maintain  a  home,  so  it  seemed  important  that  Jane  should 
spend  a  year  at  the  rescue  home,  where  she  would  have  the 
training  and  discipline  she  needed,  and  she  courageously  ac- 
cepted her  duty.  Before  she  left  the  hospital  she  had  learned 
to  love  the  dear  baby,  and  nothing  could  have  persuaded  her 
to  give  her  up.  Bringing  the  mother  and  father  of  the  baby 
together,  as  social  investigation  and  work  on  the  case  had 
done,  served  to  foster  a  growing  attachment  between  them, 
and  they  pledged  their  troth  before  Jane  left  for  the  home. 
Only  a  short  time  passed  before  the  boy-father  realized  how 


54  "  THE  HOSPITAL  AS  A  SOCIAL  AGENT  " 

much  he  loved  the  girl-mother  and  the  baby  as  well,  who  ap- 
pealed to  him  as  a  fatherless  child.  He  determined  to  have 
them  both  and  make  the  home  for  them.  His  parents  were 
willing  to  share  their  home  and  her  father  and  mother  to  assist 
with  the  family  expenses,  so  Jane  returned  to  the  city,  and  they 
were  married  in  an  Episcopal  chapel  in  the  presence  of  the 
immediate  relatives.  It  was  the  privilege  of  the  social  worker 
on  the  following  Sabbath  to  act  as  godmother  when  the  baby 
was  christened.  When  a  visit  was  made  a  year  later  they 
were  living  happily,  the  father  had  finished  his  apprenticeship, 
and  was  receiving  regular  wages.  It  is  granted  these  two  were 
not  mature  enough  to  marry  and  undertake  the  responsibilities 
of  parenthood  and  of  establishing  a  home,  but  with  the  support 
and  guidance  of  the  parents  of  both  was  it  not  best  under  the 
circumstances  to  assist  in  bringing  this  about? 

FLORENCE  AND  HER  TWINS 

One  day  in  January  the  hospital  office  called  the  social 
worker's  attention  to  a  woman  in  the  maternity  ward  who  was 
about  to  be  discharged,  but  who  seemed  to  have  no  place  to  go 
with  her  twin  babies,  and  neither  did  she  have  money  to  pay 
the  hospital  bill,  as  she  had  promised  when  she  was  admitted. 
Because  she  was  a  paid  case  she  had  not  been  interviewed  before 
by  the  social  worker.  So  it  came  about  that  at  this  late  day  the 
worker  was  presented  with  Florence  and  her  twins,  and  it  was 
found  that  Florence  was  not  married,  did  not  know  where  she 
could  go,  nor  what  to  do  with  the  babies.  Furthermore,  she 
had  no  money  to  pay  the  hospital  bill,  as  some  friend  she 
thought  she  could  rely  upon  to  furnish  the  money  did  not  ap- 
pear, and  Florence  had  no  definite  address  with  which  to  reach 
her.  This  poor  woman  was  evidently  under  par  mentally, 
this  was  her  second  offence,  she  having  a  girl  seven  years  old 
staying  with  some  people  in  the  city.  She  had  worked  at  a 
hotel  until  a  short  time  before  coming  to  the  hospital,  so  had  no 
home  to  go  to.  The  people  who  were  keeping  the  girl  would 
have  nothing  to  do  with  Florence  if  she  kept  the  babies,  and  it 
was  no  place  for  her,  as  they  were  poor  and  dirty.  As  usual, 
the  only  thing  that  seemed  could  be  done  was  to  give  the 
babies  away  and  go  back  to  work,  but,  of  course,  she  was 


FLORENCE   AND   HER   TWINS  55 

dissuaded  from  this  thought,  and  the  better  plan  was  presented 
to  her,  with  assurance  of  help  to  follow  it  out.  Commitment 
through  the  city  charities  to  a  nursery  where  she  could  take 
care  of  her  own  babies  was  secured,  and  the  transfer  was  soon 
made.  Here  she  found  a  friend  in  the  superintendent,  who  was 
a  good,  motherly,  wise  woman,  and  probably  for  the  first  time 
in  her  life  she  received  the  uplifting  encouragement  that  showed 
her  there  was  another  road  to  travel  better  than  the  one  she 
had  followed,  one  with  greater  rewards  and  more  happiness, 
because  it  was  the  right  road.  Florence  learned  to  love  and 
tend  her  babies,  and  to  be  helpful  about  the  nursery,  so  as  we 
visited  her  from  time  to  time  we  found  her  very  happy  and 
contented.  She  had  no  desire  to  go  out  nights,  she  stayed 
close  to  her  duty,  and  as  time  went  on  she  was  given  more 
general  work  to  do  and  soon  became  indispensable  to  the 
house  because  she  proved  herself  faithful  and  reliable  and 
efficient.  For  a  year  and  a  half  that  we  were  able  to  keep  in 
touch  with  her  she  was  happy,  contented,  and  useful.  This 
story  would  not  be  complete  without  relating  the  close  call 
that  Florence  had  to  being  sent  to  the  State  Reformatory 
because  of  her  seeming  irresponsibility  due  to  her  feeble- 
minded condition.  The  public  commissioner  determined  that 
there  was  no  use  in  expending  public  funds  to  support  a  woman 
who  had  no  moral  sense,  and  was  bringing  babies  into  the 
world  at  the  rate  of  two  at  a  time  for  the  community  to  take 
care  of.  A  warrent  was  issued  for  Florence's  arrest  on  a 
charge  of  dependence.  The  poor  woman  was  brought  to  the 
city  jail  the  night  before  the  time  set  for  trial,  leaving  her 
babies  crying  for  food,  and  she  herself  suffering  the  discomforts 
of  engorged  breasts.  When  she  appeared  in  the  court  room 
she  was  frightened  and  bewildered,  and  did  not  know  how  to 
answer  the  judge's  questions.  The  court's  decision  was  soon 
made  that  she  should  be  sent  to  the  State  Reformatory.  Just 
at  this  point  the  police  matron  appeared  with  a  message  from 
the  superintendent  of  the  nursery,  asking  that  Florence  he 
given  six  months'  probation  and  left  at  the  nursery,  as  she  had 
already  shown  an  improvement,  and  they  were  glad  to  do  all 
in  their  power  to  help  her  in  the  upward  road.  The  judge 
granted  this  request,  and  Florence  was  returned  to  the  nursery 


\ 


56  "  THE  HOSPITAL  AS  A   SOCIAL  AGENT  " 

a  happy  woman  and  warmly  greeted  by  her  babies.  The 
commissioner  was  the  unhappy  one  after  this  because  he  had 
not  accomplished  his  desire,  and  he  consoled  himself  by  with- 
drawing the  city  support  for  Florence  at  the  nursery.  She 
was  retained,  however,  at  their  own  expense,  and  in  time 
earned  not  only  her  own  board  but  was  given  wages.  While 
it  is  granted  this  woman  was  mentally  weak,  and  in  so  far  irre- 
sponsible, the  results  justified  the  trial  she  was  given  to  make 
good,  and  the  good  influences  thrown  about  her  were  as  ef- 
fectual as  the  evil  ones  had  formerly  been.  She  was  just  weak 
minded  enough  to  be  influenced  either  way,  but  why  should 
she  not  be  given  the  chance  to  find  her  place  in  the  world  when 
she  displayed  the  ability  for  good  work  that  she  did? 

Both  of  these  had  their  far-reaching  influence  in  the  com- 
munity, which  will  be  readily  recognized,  and  society  was 
benefited,  as  it  always  is,  when  these  girls  are  taught  to  pro- 
tect themselves  and  others  against  a  repetition  of  the  same 
offence.  The  baby  is  a  tie  which  holds  the  mother.  If  she 
is  relieved  of  her  burden,  it  falls  upon  the  community,  and 
leaves  her  free  to  travel  the  same  road  again  and  add  another 
burden.  It  is  not  an  easy  road  for  the  girl,  for  she  finds  her- 
self alone  in  the  midst  of  difficulties  and  perplexities  which 
are  naturally  shared  with  the  partner,  and  for  this  reason 
she  should  have  the  encouraging,  uplifting,  helpful  influences 
and  surroundings  to  hold  her  to  the  path  of  duty. 

One  factor  is  important  in  these  cases  which  we  must  not 
lose  sight  of.  Remember  that  we  are  dealing  with  the  result 
of  one  of  the  strongest  of  human  passions.  This  thought 
should  modify  our  first  natural  feeling  of  disgust,  and  the 
tendency  to  attach  merciless  blame  to  either  party  concerned. 
God  has  endowed  man  with  this  passion,  and  made  it  an 
overpowering,  ruling  one,  that  the  race  may  be  preserved  to  the 
end  of  time.  This  passion  is  the  impelling  force  in  all  of  man's 
activities,  and  nature  demonstrates  that  the  stronger  this 
impelling  force  is,  the  greater  are  man's  activities.  It  is  the 


THE   PROBLEM   OF   THE   UNMARRIED   MOTHER  57 

power  that  moves  the  world.  Nature  proves  that  all  things 
that  have  life  possess  the  power  of  reproduction,  and  the  con- 
stant struggle  is  to  preserve  life  through  this  power.  In  man 
only  has  the  Creator  placed  a  censor  for  the  control  of  this 
power  by  the  use  of  the  will,  and  just  so  far  as  man  recognizes 
his  moral  obligation  and  lives  up  to  the  rules  and  customs  of 
society  this  censor  will  keep  him  within  the  bounds  of  what 
we  term  "right  living."  However,  "right"  is  a  relative  term, 
who  can  define  it  absolutely?  Our  standards  are  high  com- 
pared with  those  of  some  others  who  are  constantly  thrown 
into  temptation,  and  it  is  easier  for  us  to  maintain  our  high 
standard  than  it  is  for  those  others  to  resist  the  promptings 
of  this  powerful  impulse  in  the  midst  of  temptations  to  uphold 
a  standard  that  is  lower. 

There  are  others  who  have  no  moral  standard,  and  who 
recognize  no  moral  obligation.  They  do  not  fall,  they  are 
only  following  nature's  impulses  and  demands,  scarcely  know- 
ing that  it  is  a  sin  to  yield  to  these  impulses  indiscriminately. 
Another  class  know  what  their  moral  duty  is  in  this  respect, 
and,  as  a  rule,  fulfil  it,  but  temptation  comes,  the  impulse 
is  stronger  than  the  will,  and  the  censor  is  removed.  This 
group  furnishes  many  of  the  cases  with  which  the  hospital 
social  worker  in  the  smaller  communities  comes  in  contact, 
and  her  sympathetic,  tactful  handling  of  them  is  sure  to 
spare  many  a  good,  right-meaning  girl  from  social  ostracism 
or  from  drifting  into  a  life  of  degradation. 

In  dealing  with  the  unmarried  mother  in  the  hospital  ward 
we  must  accept  her  in  her  present  situation,  determine  what 
her  moral  standards  are,  and  what  should  be  done  for  her 
best  good  and  for  the  good  of  the  community  and  society.  A 
good  religious  influence  is  important  with  many  of  these 
girls,  but  if  we  try  to  make  it  a  panacea,  we  lose  sight  of  the 
different  types  of  girls  and  of  the  causes,  within  and  without, 
which  bring  about  the  unfortunate  results. 


CHAPTER  VI 

THE  PROBLEM  OF  THE  HOSPITAL  CHILD 

THE  children's  ward  is  one  of  the  most  interesting  places 
in  the  hospital.  Because  of  the  child's  helplessness  and  de- 
pendence he  always  finds  a  benefactor  when  in  need,  but  the 
sick  or  injured  child  especially  calls  forth  universal  sympathy. 

The  children's  ward  is  interesting  to  the  social  worker 
because  of  the  varied  problems  of  vital  importance  which  are 
offered  for  solution.  The  recognition  of  a  lifelong  handicap 
through  disease,  deformity,  or  injury  calls  forth  far-reaching 
sympathy,  which  outweighs  pity  for  present  suffering  and 
leads  to  intensive  work  for  the  welfare  of  the  child.  Our 
little  Baltomero,  whose  story  is  recorded  on  page  62,  suffered 
for  weeks  from  the  many  operations  he  underwent  to  make 
for  him  better  hands,  but  how  little  did  that  count  compared 
with  the  deleterious  effects  of  dependence  resulting  from  such  a 
handicap  as  his?  This  child  was  one  of  the  bright  spots  in  the 
experience  of  the  worker.  He  was  so  lovable  and  showed 
signs  of  such  a  bright  mind  it  was  a  joy  to  receive  his  greeting 
each  day  on  the  ward,  and  to  know  that  there  was  opportunity 
for  lasting  service  to  him. 

The  encouraging  feature  of  the  work  with  children  is  the 
advantage  to  be  gained  by  early  service,  and  the  opportunity 
for  prevention  which  is  thus  afforded.  This  fact,  coupled  with 
a  natural  interest  in  children,  furnishes  an  incentive  for  real 
active  work.  Take  the  six  children  on  the  car  who  were  snap- 
ped while  on  their  way  to  the  roof  garden,  they  are  all  tuber- 

58 


Fig.  4. — A  group  from  the  children's  ward. 


Fig.  5. — On  the  way  to  the  roof  garden. 


THE  PROBLEM  OF  THE  HOSPITAL  CHILD        59 

culous  or  syphilitic.  How  important  that  their  treatment 
should  be  started  now  and  continued  until  they  are  well. 
Annie's  open  sinus  and  Angeline's  may  be  healed  if  taken 
in  time.  Gisella's  tubercular  hip  needs  attention  before  the 
disease  gains  headway.  Josie  and  Barbie  with  rachitic  legs 
may  be  helped  by  treatment  now  while  the  bones  are  soft. 

All  of  these  children  were  greatly  benefited  by  their  hos- 
pital care,  and  the  social  service  rendered  is  beyond  question. 
It  required  a  great  deal  of  encouragement  and  persuasion 
and  friendly  advice  on  the  part  of  the  worker  to  hold  them  until 
the  medical  and  surgical  work  could  be  completed,  and  in  the 
case  of  Angeline,  whose  story  is  coupled  with  that  of  Mary 
(page  63),  she  became  a  real  social  problem. 

It  is  sometimes  necessary  to  institute  court  proceedings 
against  the  parents  in  order  to  obtain  for  the  child  the  hos- 
pital care  which  is  necessary  to  save  him  from  being  an  un- 
fortunate cripple.  This  is  not  resorted  to,  of  course,  until 
all  other  methods  of  persuasion  have  failed. 

A  two-year-old  girl,  with  a  corneal  ulcer  which  was  the 
result  of  the  parents'  neglect  to  give  her  proper  care,  was 
obliged  to  lose  the  eye  because  it  had  ruptured.  The  infec- 
tion would  have  extended  to  the  other  eye  if  the  diseased 
one  had  not  been  removed,  and  total  blindness  would  have 
resulted.  No  amount  of  persuasion  or  threatening  moved  the 
parents  to  consent  to  the  removal  of  the  child's  eye,  so  it  was 
necessary  to  bring  them  into  juvenile  court  for  neglect.  The 
judge  issued  orders  for  Eva  to  be  retained  in  the  hospital  as 
long  as  it  was  necessary,  and  the  doctor  was  permitted  to 
carry  out  the  treatment  which,  in  his  judgment,  would  pre- 
vent blindness. 

The  story  of  Charles  on  page  64  illustrates  the  necessity 
at  times  of  asking  for  the  help  of  the  court  to  obtain  treat- 
ment that  preventive  measures  may  be  carried  out. 


60        "  THE  HOSPITAL  AS  A  SOCIAL  AGENT  " 

It  is  the  duty  of  society  to  protect  the  innocent,  helpless 
members,  and  this  duty  is  performed  partly  in  self-defense. 
The  strong  are  responsible  for  the  weak,  and  if  children  are 
in  danger  of  becoming  the  victims  of  the  ignorance  and  stub- 
bornness of  parents,  the  better  members  of  society  who  are 
capable  of  recognizing  the  danger  signals  should  serve  as  the 
children's  defense.  Parents  have  their  rights,  but  individual 
rights  and  those  of  society  must  take  precedence  in  a  critical 
moment. 

Lest  the  overzealous  worker  in  the  small  community 
should  be  led  into  error  through  a  misuse  of  this  idea  of  duty, 
it  must  be  repeated  that  the  court  is  a  last  resort.  Sometimes 
the  sacrifice  of  one  child  will  strengthen  the  cause  of  all  others 
to  follow,  and  a  misdirected  plan  to  force  parents  may  be  the 
means  of  losing  their  confidence,  and  the  social  worker  loses 
her  opportunity  for  valuable  service. 

The  greatest  wisdom  and  foresight  is  necessary  in  handling 
many  of  the  acute  problems.  It  is  a  terrible  thing  to  see  a  child 
suffer,  and  to  know  that  it  is  innocently  bearing  the  pain 
inflicted  by  someone  who  is  either  ignorant  or  evil.  But  the 
wrongs  may  not  all  be  righted  in  a  day,  and  it  is  the  ultimate 
good  to  the  greatest  number  that  must  determine  the  best 
methods  of  procedure  in  individual  cases.  Many  things 
must  be  taken  into  consideration.  Parents  are  prejudiced 
by  their  love  for  the  child,  and  although  it  may  be  more  of  an 
animal  love  than  human  it  must  be  recognized,  and  often  the 
best  way  to  win  them  is  to  gain  their  confidence  by  taking 
their  point  of  view.  Then,  parents  have  their  rights,  and 
those  rights  are  just,  as  far  as  their  responsibility  goes.  Ig- 
norance may  be  due  to  superstition  which  influences  them, 
and  superstition  is  very  hard  to  overcome.  Again,  we  must 
be  able  to  answer  the  question,  What  method  of  action  will 
gain  our  point  or  bring  about  the  best  results? 


THE   PROBLEM    OF    THE   HOSPITAL   CHILD  6 1 

Sometimes  our  hands  are  tied,  and  it  is  impossible  to  ob- 
tain the  co-operation  from  other  agencies  to  properly  place  a 
child  for  care  when  he  leaves  the  hospital.  This  was  the  diffi- 
culty with  little  Mary  who  is  pictured  with  Angeline.  It 
may  be,  pressure  enough  cannot  be  brought  to  bear  upon 
proper  authorities  to  improve  sanitary  and  living  conditions 
which  are  responsible  for  the  illness  of  the  baby,  and  the  work 
of  hospital  physicians  is  wholly  undone  when  the  child  returns 
home.  Indeed,  there  are  many  stone  walls  which  we  cannot 
climb  over,  but  some  day  an  opening  will  be  made  through 
which  we  may  freely  pass,  if  we  continue  our  efforts  persist- 
ently. 

If  we  would  win  in  many  of  these  difficult  problems  we 
must  establish  public  confidence  by  the  careful,  practical 
handling  of  case  work.  Social  workers  should  have  definite 
knowledge  of  facts  through  complete  investigation,  a  definite 
problem,  and  a  definite  plan  of  action. 

The  hospital  child  presents  such  vital  problems,  and  our 
love  and  sympathy  play  such  a  large  part,  the  work  receives 
an  impetus  which  assures  ultimate  success  with  any  undertak- 
ings in  his  behalf.  The  child  will  some  day  be  the  man,  and 
service  to  the  child  is  service  to  the  man.  In  other  words, 
disease  overcome  in  childhood,  or  a  strong  constitution  es- 
tablished through  proper  feeding  and  care  of  the  infant, 
lay  the  foundation  for  the  making  of  a  man  equal  to  his  task 
in  the  world.  All  through  his  life  he  will  be  an  asset  in  the 
community  instead  of  a  liability.  This  is  the  sum  and  sub- 
stance of  all  social  work,  and  the  work  with  children  offers 
great  opportunities  in  this  direction. 

Just  here  may  be  mentioned  an  important  service  in  the 
out-patient  department,  because  it  has  to  do  with  making 
better  babies,  who  stand  a  better  chance  to  become  strong 
men. 


62  "THE  HOSPITAL  AS  A  SOCIAL  AGENT" 

In  small  communities  an  out-patient  obstetric  service  may 
be  maintained  through  the  co-operation  of  the  district  nurses. 
The  prospective  mother  is  given  a  complete  examination 
in  the  dispensary,  including  urinalysis,  and  is  then  placed 
on  the  waiting  register  for  outside  delivery.  The  case  is  re- 
ported at  once  to  the  district  nurses,  who  take  up  the  pre- 
natal care.  The  patient  is  delivered  in  her  own  home  by  a 
doctor  and  nurse  from  the  hospital  and  the  district  nurse 
follows  with  postnatal  care.  This  plan,  with  slight  variations, 
is  in  operation  in  a  number  of  places,  and  may  be  handled  in 
any  hospital  with  the  dispensary  under  social  service  super- 
vision. 

There  is  no  question  as  to  the  value  of  such  a  service  to 
the  mothers  and  babies.  Many  of  the  ills  which  follow  child- 
birth attended  by  mid  wives  and  careless  doctors  are  averted; 
the  danger  to  the  baby  from  infected  eyes  is  lessened  100  per 
cent.,  and  the  close  touch  with  its  accompanying  influences, 
which  is  thus  obtained  for  two  important  social  agencies, 
gains  an  effectual  vantage  point.  Better  mothers  and  better 
babies  must  result  from  this  kind  of  service,  and  the  cribs 
in  the  children's  ward  would  go  begging  for  the  poor  little 
starved  creatures  which  never  had  a  fair  start  in  life. 

BALTOMERO 

Baltomero  was  eighteen  months  old  when  he  was  admitted 
to  the  hospital.  His  parents  were  Italians,  living  in  a  poor 
quarter  of  the  city  in  crowded  rooms.  Since  birth  he  had  had 
webbed  ringers,  and  he  was  brought  to  the  hospital  to  see  if 
something  could  not  be  done  to  improve  his  crippled  hands. 
The  surgeon  operated  several  times,  cutting  down  between  the 
bones  that  were  at  all  normal,  and  making  separate  fingers  as 
far  as  possible.  Since  the  child  gains  much  knowledge  through 
the  manipulation  of  his  hands,  this  boy  was  in  danger,  through 
his  handicap  and  through  ignorance  of  the  parents,  of  losing 


Fig.  6. — Baltomero. 


m 


Fig.  7. — Mary  and  Angeline. 


MARY   AND   ANGELINE  63 

much  natural  brain  development  if  he  did  not  learn  to  use 
these  new  fingers.  As  soon  as  he  was  old  enough  for  kinder- 
garten he  should  be  started  there,  but  in  the  meantime  he 
should  be  taught  to  handle  his  food,  playthings,  books,  etc., 
and  so  it  was  essential  that  no  time  be  lost.  Visiting  at  the 
home,  the  mother  was  shown  how  to  give  him  playthings  of 
different  shapes  and  forms,  and  the  social  worker  took  blocks 
and  other  things  to  him  to  demonstrate  to  the  mother  what 
was  necessary.  It  was  most  gratifying  to  notice  how  his 
little,  bright  mind  and  determined  spirit  taught  him  naturally 
because  there  were  placed  before  him  the  things  that  were 
attractive  to  him.  Nothing  was  too  hard  for  him  to  attempt 
to  do.  He  learned  to  hold  a  spoon  and  feed  himself  with  it, 
and  could  pick  up  a  dime  which  was  offered  him  as  a  bribe, 
following  the  much  used  custom  of  foreign  parents.  Realizing 
that  such  supervision  needed  to  be  carried  on  for  years  to  come, 
the  social  worker  felt  it  would  be  best  to  place  the  child  under 
the  care  of  a  permanent  agency  in  the  community,  and  so  the 
case  was  placed  before  the  Children's  Aid  Society  for  considera- 
tion. After  investigation,  they  agreed  to  assume  this  super- 
vision, and  a  visitor  began  regular  visits  to  the  home. 

MARY  AND  ANGELINE 

The  two  children  seen  in  the  picture  are  grouped  together 
because  they  were  in  the  hospital  ward  at  the  same  time,  and 
because  they  are  poor,  dear  children  whom  no  one  wants,  yet 
must  be  cared  for  somewhere  by  someone.  Both  are  diseased, 
Mary,  on  the  left,  having  a  congenital  syphilitic  condition,  pro- 
ducing an  ever-recurrent  eye  trouble;  Angeline,  on  the  right, 
suffering  from  bone  tuberculosis,  appearing  at  different  times 
in  different  places.  It  will  be  noticed  the  middle  finger  of  her 
right  hand  is  amputated,  this  being  done  when  she  was  but 
eighteen  months  of  age.  Mary's  mother  died  when  she  was 
one  year  old ;  her  father  was  too  feebleminded  to  support  him- 
self or  even  to*  give  Mary  the  daily  care  she  needed,  and  he 
died  in  the  County  Infirmary  from  cancer.  With  such  a 
family  history  and  such  a  physical  condition  even  the  Chil- 
dren's Home  did  not  want  her,  the  hospital  could  not  keep  her 


64  "THE  HOSPITAL  AS  A  SOCIAL  AGENT" 

all  her  life,  and  no  one  would  adopt  her.  After  two  years  of 
supervision  and  hospital  care  she  was  taken  over  by  the  State 
Board  of  Charities,  who  will  see  that  she  has  all  that  can  be 
provided  for  her  welfare  as  long  as  she  lives.  Angeline  has  a 
mother,  but  she  is  more  irresponsible  than  not,  and  has  left 
Angeline  to  the  tender  mercies  of  others,  so  she  might  be  free 
to  go  her  way  as  she  chose.  Fully  half  of  the  time  the  past 
three  years  the  child  has  been  in  the  hospital,  sometimes  with 
three  discharging  sinuses.  The  mother  finally  married,  and 
it  has  been  our  task  to  insist  upon  her  keeping  Angeline  and 
caring  for  her,  although  many  times  she  has  come  and  begged 
to  leave  her  in  the  hospital.  The  grandmother,  who  has  kept 
the  child  much  of  the  time,  is  now  too  old  to  have  the  responsi- 
bility, and  the  mother,  who  seems  fond  of  her,  is  now  in- 
fluenced by  her  husband  to  put  her  away  because  of  her 
disease.  So  it  has  been  a  struggle  to  keep  Angeline  where  she 
belongs,  hi  her  mother's  home.  One's  heart  naturally  goes 
out  to  these  little  ones  who  are  unwelcome  guests,  yet  they 
present  one  of  the  most  difficult  problems. 

CHARLES 

Charles  was  three  and  a  half  years  of  age  when  referred 
from  the  dispensary  to  the  hospital  for  treatment  of  a  possible 
injury  to  his  hip.  His  parents  were  Germans,  and  the  mother 
was  loath  to  leave  him  for  fear  he  would  cry,  and  as  he  under- 
stood nothing  but  German  she  thought  he  would  not  be  able 
to  make  his  wants  known.  Her  fears  were  allayed  and  she 
consented  to  let  him  stay.  How  little  did  the  social  worker 
realize  that  this  was  the  beginning  of  desperate  struggles  with 
these  parents  to  give  this  child  what  he  must  have  to  prevent 
his  being  a  lifelong  cripple.  Examination  in  the  hospital 
showed  the  hip  was  tuberculous,  and  the  only  treatment  was 
the  application  of  an  extension  and  weights.  Before  doing 
this  the  doctor  asked  the  social  worker  if  she  would  see  the 
parents  and  explain  the  treatment,  and  find  if  they  would  con- 
sent to  it  and  to  the  child's  staying  several  months,  as  it  would 
necessarily  take  a  long  time.  The  worker  visited  the  home, 
and  told  the  parents  that  the  trouble  was  a  disease  of  the  hip 


Fig.  8.— Charles. 


CHARLES  65 

and  not  an  injury,  and  if  the  child  was  allowed  to  go  without 
treatment  the  disease  would  progress  and  the  limb  grow 
shorter,  resulting  in  a  crippled  boy.  As  the  father  had  received 
an  injury  more  than  a  year  ago  which  had  crippled  him,  the 
appeal  was  made  that  he  surely  would  have  everything  done 
for  his  boy  to  prevent  such  suffering  and  dependence.  They 
said  they  were  willing  to  have  the  doctor  go  on  with  the  treat- 
ment which  he  thought  was  necessary,  and  they  would  leave 
Charles  in  the  hospital  as  long  as  it  was  best.  This  cleared 
the  way  for  the  doctors,  and  they  applied  the  weights  for  the 
beginning  of  the  treatment.  Imagine  the  consternation  of  the 
intern  when  he  was  called  to  the  ward  the  next  day  and  found 
the  mother  there  in  a  state  of  great  excitement.  She  had 
loosened  the  stays  and  released  the  weights,  completely  un- 
doing the  work  which  the  intern  had  so  carefully  finished  but  a 
short  time  before.  She  was  demanding  Charles'  clothes  and 
preparing  to  take  him  home,  for  she  said  it  was  cruel  treatment, 
and  no  amount  of  argument  could  persuade  her  that  it  was 
the  kindest  thing  that  could  be  done  for  him.  After  signing  a 
release  she  took  him  home.  The  next  day  the  case  was  re- 
ported to  the  Humane  Society,  asking  if  they  could  help  in 
forcibly  retaining  the  child  in  the  hospital.  The  result  was 
that  the  agent  went  with  the  social  worker  to  the  home,  and 
found  the  parents  indignant  because  Charles  had  been  hurt; 
they,  in  their  ignorance,  could  see  no  farther  than  the  child's 
tears,  and  those  were  increased  by  the  solicitude  of  the  mother. 
They  were  told  that  they  were  neglecting  the  child,  and  if  they 
did  not  bring  him  to  the  hospital  and  leave  him  for  proper 
treatment  a  warrant  would  be  issued  for  their  arrest.  They 
then  consented,  and  brought  him  the  following  day.  The 
child  remained  for  some  months  under  the  order  of  the  Humane 
Society,  but  a  great  deal  of  trouble  was  experienced  with  the 
parents;  they  were  ugly  and  unreasonable  at  times.  After  a 
siege  with  scarlet  fever,  contracted  on  the  ward,  it  was  thought 
best  to  let  Charles  go  home  and  return  to  the  dispensary  for 
observation.  His  father  brought  him  back  just  once,  and  al- 
though visit  after  visit  was  made  to  the  home,  they  flatly  re- 
fused to  bring  him.  It  was  evident  the  disease  was  progressing, 
for  the  child  was  looking  pale  and  thin,  and  he  could  not  stand 


66         "  THE  HOSPITAL  AS  A  SOCIAL  AGENT  " 

or  walk.  Finally,  after  repeated  efforts  of  the  social  worker, 
the  father  brought  Charles  to  the  dispensary  and  the  doctor 
found  that  both  hips  were  now  involved,  and  the  only  thing  for 
the  child  was  to  place  him  in  the  hospital.  As  the  father  was 
ugly  and  demanding  at  this  time,  trying  to  dictate  the  kind  of 
treatment  the  boy  should  have  if  he  left  him,  the  only  course 
to  pursue  with  success  was  to  get  control  of  the  case  through 
the  intervention  of  the  court.  The  matter  was  taken  up  with 
the  Humane  Society  again  to  get  a  court  order  to  hold  Charles 
for  treatment  without  any  interference  from  the  parents  as 
long  as  the  doctors  deemed  it  best.  This  was  accomplished, 
and  Charles  is  receiving  every  attention  that  his  case  demands. 
The  court  told  the  father  that  he  and  his  wife  must  not  inter- 
fere in  any  way  with  the  hospital,  that  if  they  did  the  work- 
house sentence  which  the  court  imposed  would  be  carried  out, 
otherwise  it  would  be  suspended.  Even  after  this  it  was 
necessary  to  exclude  them  from  the  hospital  as  visitors, 
because  they  came  one  evening  under  the  influence  of  liquor 
and  threatened  to  make  trouble. 


CHAPTER  VII 

HUMAN  ECONOMY  AND  ECONOMY  OF 
RESOURCES 

MUCH  that  has  been  said  in  previous  chapters  bears  more 
or  less  directly  upon  the  conservation  of  human  energy  and 
the  economy  of  resources  in  the  community,  so  we  will  en- 
deavor now  to  gather  together  the  important  points  and 
clinch  them. 

After  all,  human  economy  is  our  object  in  social  work.  By 
eliminating  the  unfit,  we  strengthen  the  beings  that  remain; 
by  repairing  the  injured  or  crippled  member,  we  literally 
put  individuals  on  their  feet  and  give  them  to  the  world  for 
useful  service;  by  effecting  a  cure  in  the  best  possible  way  and 
the  least  time,  we  may  not  only  spare  a  life,  but  make  it 
yield  more  abundantly  in  energy  for  the  world's  work;  by 
taking  care  of  the  mother's  problem  in  the  home  so  as  to  make 
it  possible  for  her  to  take  necessary  treatment  in  the  hospital, 
we  economize  her  strength  and  vitality  for  use  in  her  family; 
her  children  are  better  physically,  mentally  and  morally  for 
her  best  care,  and  they  will  be  more  to  the  world. 

The  following  stories  of  Josie  and  Frankie  illustrate  the 
economic  value  of  social  service  in  putting  individuals  on 
their  feet. 

JOSIE 

Josie  was  three  years  old,  but  owing  to  a  congenital  condi- 
tion he  had  never  been  able  to  walk.  The  visiting  nurse 
found  him  sitting  on  the  floor  or  in  a  chair  trying  to  amuse 
himself,  and  determined  that  something  should  be  done  to 

67 


68  THE  HOSPITAL  AS  A  SOCIAL  AGENT  " 

better  his  condition  if  possible.  She  brought  him  to  the  dis- 
pensary for  examination,  and  the  doctor  referred  him  to  the 
hospital  ward  for  treatment.  Josie's  father  had  died  a  few 
months  before,  leaving  the  mother  with  three  children  and 
pregnant.  A  widow's  pension  was  secured  for  her  and  help 
from  a  relief  agency,  that  she  might  take  care  of  her  children 
herself.  But  Josie  was  bound  to  grow  up  a  helpless,  dependent 
child  unless  something  was  done  to  straighten  his  legs  and  make 
them  strong  enough  to  hold  him  up  and  to  be  of  use  in  walking. 
The  mother  had  a  great  enough  task  to  keep  her  family  together 
without  having  a  crippled  child  to  support,  to  say  nothing  of  the 
boy,  whose  whole  life  would  be  marred  by  this  handicap.  The 
problem  in  this  case  was  to  direct  the  medical  social  service 
toward  making  a  normal  child  who  would  be  capable  of  taking 
and  holding  a  normal  place  in  the  home  and  in  the  community. 
These  facts  were  given  to  the  doctor,  who  at  once  became 
interested,  and  set  to  work  to  build  up  the  physical  condition 
of  the  child  ready  for  the  operation.  Josie  was  especially 
bright  and  attractive,  becoming  a  favorite  with  everyone  in  the 
hospital,  and  he  was  given  every  opportunity  with  medicine, 
food,  and  fresh  air  to  prepare  for  what  was  before  him.  Finally 
the  doctor  operated  on  his  legs,  putting  them  in  casts,  as  he  is 
seen  in  the  picture.  In  his  usual  happy  disposition,  Josie 
spent  the  weeks  in  this  constrained  position  waiting  for  the 
day  when  he  should  be  free  from  the  fetters  whose  purpose 
was  a  mystery  to  him.  The  great  day  came  at  last  when  the 
casts  were  removed,  and  it  was  only  surpassed  by  the  day 
when  he  stood  for  the  first  time  in  his  life  on  both  feet.  He 
soon  learned  to  walk,  and  the  social  worker  was  instructed  by 
the  doctor  to  obtain  proper  shoes  that  would  give  the  support 
he  needed  until  he  gained  strength  in  his  feet  and  ankles.  Any- 
one witnessing  the  mother's  joy  and  gratitude  when  she  took 
Josie  home  would  feel  that  time,  money,  and  efforts  had  been 
well  spent  in  putting  this  boy  literally  on  his  feet.  Josie  now 
has  a  new  father,  the  family  are  living  in  the  country,  are  self- 
sustaining,  and  in  a  position  to  continue  so,  and  the  case  has 
been  closed  by  the  different  organizations  assisting.  The 
derrick  has  lifted  the  load,  swung  it  about,  dumped  it  on  new 
ground,  and  reconstruction  has  been  accomplished. 


jkifl 


Fig.  9. — Josie  in  casts. 


-  i 


Fig.  10. — Josie  returned  to  his  family. 


FRANKIE  69 

Several  important  principles  in  social  work  are  illustrated 
in  this  case.  First  and  foremost,  the  individual  was  trans- 
ferred from  the  dependent  class  to  the  independent;  second, 
the  family  was  kept  together,  and  through  the  close  touch  of 
different  organizations  the  mother  was  taught  many  things 
of  value  about  the  care  of  her  children,  and  the  moral  support 
she  received  helped  to  make  her  a  better  home-maker;  third, 
the  Home  for  Crippled  Children  was  robbed  of  one  poor 
victim,  and  the  dismal,  dark  room  where  Josie  spent  his  days 
lost  the  child  who  now  runs  about  wherever  he  will,  playing 
like  other  children;  fourth,  the  case  demonstrated  the  need 
for  hospital  social  service,  and  shows  its  place  in  the  commun- 
ity. There  is  no  question  of  the  economy  of  individual  and 
public  resources. 

FRANKIE 

Five-year-old  Frankie  was  brought  to  the  hospital  with 
badly  crushed  legs,  having  been  run  over  by  an  engine  while 
"  hopping  trams/'  as  he  himself  said.  The  surgeon  found  there 
was  no  hope  of  saving  his  limbs,  and  it  was  necessary  to  am- 
putate them  at  once.  He  made  a  good  recovery,  and  in  time 
was  completely  healed  and  ready  to  leave  the  hospital,  but 
where  was  he  going  and  what  was  he  to  do,  with  his  whole  life 
before  him  and  no  means  of  locomotion?  He  had  been  living 
with  his  uncle  and  aunt  in  a  mere  shack  of  a  place,  under  the 
worst  home  conditions  that  could  be  imagined — drunkenness, 
dirt,  and  shiftlessness  abounding.  His  parents  were  Slavish, 
but  nothing  is  known  of  them  or  any  other  members  of  his 
family  except  an  older  brother,  who  came  to  see  him  later. 
His  uncle  and  aunt  soon  stopped  visiting  him  at  the  hospital, 
for  they  considered  him  no  good  to  them,  and  as  he  was  devel- 
oping into  a  very  lovable,  bright  boy  their  home  was  not  the 
place  for  him.  The  first  thing  to  investigate  was  the  arti- 
ficial limb  proposition,  and  see  if  he  could  be  fitted  at  so  early 
an  age.  This  was  found  entirely  possible,  and  a  subscription 
was  started  to  raise  the  necessary  funds.  Among  nurses, 
officers,  and  doctors  at  the  hospital,  friends,  railroad  officials, 


70  THE  HOSPITAL  AS  A  SOCIAL  AGENT  " 

and  hospital  board  the  sum  of  $200  was  raised  and  the  limbs 
were  ordered.  At  Christmas  tune  Frankie  received  the  gift 
of  a  little  wagon,  with  which  he  pushed  himself  all  about  the 
hospital.  He  was  so  agile  he  climbed  about  like  a  monkey, 
and  no  task  was  too  hard  to  deter  him  from  attempting.  These 
qualities  showed  what  there  was  in  the  boy  to  make  him  worth 
while.  The  day  came  when  Frankie  was  to  go  to  a  nearby 
city,  where  his  limbs  were  being  made,  to  have  them  tried  on, 
and  the  journey  was  a  wonderful  experience  for  him.  As  one 
night  must  be  spent  in  the  city,  arrangements  were  made  with  a 
sister  hospital  to  care  for  him.  When  he  returned  the  days 
seemed  long  awaiting  the  arrival  of  the  "new  legs,"  as  he 
called  them,  but  at  last  they  came,  and  there  never  was  a 
prouder,  happier  boy  than  he  when  he  stood  on  them  and 
realized  that  he  was  to  be  like  other  boys  again,  or  nearly  so. 
As  soon  as  he  could  get  about  without  help  he  was  transferred 
to  the  County  Children's  Home,  and  so  became  a  county 
ward.  Frankie  has  made  a  place  for  himself  in  this  home, 
is  much  beloved,  goes  to  school  with  other  children,  and  is 
waiting  for  someone  to  love  him  hard  enough  to  adopt  him. 

So  we  might  go  on,  showing  specific  examples  of  medico- 
social  work  directed  toward  human  economy.  Every  indi- 
vidual member  of  society  is  needed  for  some  part  of  the  world's 
work,  and  just  so  far  as  he  is  unfit  for  his  job  the  world  in 
some  degree  suffers.  Our  task,  then,  is  to  eliminate  the  evil 
and  dangerous  influences,  to  effectively  repair  waste  and 
damage,  and  to  create  wholesome  surroundings  for  human 
beings.  It  is  the  whole  man,  physical,  mental,  and  moral, 
that  must  have  consideration,  as  the  normal  or  abnormal 
condition  of  one  part  affects  the  others.  Jack  London  says, 
"Men  cannot  be  worked  worse  than  a  horse  is  worked,  and 
be  housed  and  fed  as  a  pig  is  housed  and  fed,  and  at  the  same 
time  have  clean  and  wholesome  ideals  and  aspirations." 
This  is  only  too  true,  and  the  trend  of  the  present  age  is  to 
bring  about  the  adjustment  of  affairs  and  conditions  so  that 


Fig.  11. — Frankie,  after  three  years  in  the  home. 


HUMAN   ECONOMY  71 

human  energy  will  be  conserved  and  used  to  the  best  advan- 
tage. 

There  are  many  individuals  who  form  a  part  of  society 
who  do  not  appreciate  values  in  any  way;  their  life  is  more  or 
less  of  an  existence  without  thought  of  economy  or  any  day 
beyond  today.  Neither  do  they  realize  their  relation  to  other 
members  of  society,  so  live  independently  and  freely.  Those 
who  do  understand  values  and  relations  have  a  deep  responsi- 
bility for  the  education  of  the  rest,  and  for  the  forcible  ad- 
justment that  is  necessary  for  the  protection  of  all  classes. 

In  this  matter  of  human  economy  the  hospital  is  deeply 
concerned,  for  it  is  dealing  with  the  physical  energy  in  man. 
As  it  was  stated  in  a  previous  chapter,  the  patient  who  is 
forced  by  reason  of  circumstances  to  seek  free  or  part  free 
treatment  is  entitled  to  the  best  service  that  can  be  provided, 
and  the  hospital  organization  must  be  equal  to  this  demand. 
The  medical  staff  is  a  most  important  part  of  the  organization, 
and  the  guards  at  the  entrance  should  be  so  watchful  that  it 
is  impossible  for  any  unscrupulous  or  self-centered  doctor 
to  gain  admission.  Viewing  the  hospital  from  the  side  of  its 
responsibility  as  a  social  agent  in  the  community,  nothing 
is  more  deleterious  to  its  life  and  growth  than  to  have  on  its 
medical  staff  physicians  and  surgeons  who  are  careless  and 
indifferent  in  the  performance  of  their  duties,  or  who  make 
free  patients  the  victims  of  exploitation.  Some  doctors  of 
this  type  in  their  private  practice  obtain  money  from  ignorant, 
unsuspecting  people  who  receive  no  benefit,  and  when  their 
money  is  gone  they  are  obliged  to  seek  free  treatment  either 
in  the  dispensary  or  hospital.  Fortunate  are  they  if  the 
delay  has  not  jeopardized  their  chance  for  recovery. 

Knowing  these  facts,  then,  are  not  social  workers  who 
admit  patients  for  dispensary  service  justified  in  accepting 
a  person  for  treatment  who  is  ignorant  enough  to  become  a 


72  "  THE  HOSPITAL  AS  A  SOCIAL  AGENT  " 

prey  to  such  doctors?  And  in  sparing  such  a  victim  are  we 
not  relieving  the  public  from  a  possible  danger  or  burden? 
We  would  refer  to  Chapter  II  (p.  21),  where  the  duties  of 
the  admitting  officer  are  spoken  of. 

There  is  another  class  of  persons  we  believe  to  be  eligible 
to  dispensary  service.  It  is  those  whose  financial  resources 
should  be  conserved  either  for  the  support  of  the  family  or 
for  the  waning  human  forces  which  will  be  soon  exhausted. 
Again,  there  is  a  class  of  patients  whose  condition  is  such  that 
if  the  complete  facilities  offered  in  the  hospital  and  dispen- 
sary are  made  use  of  there  is  every  chance  for  their  full  re- 
covery, whereas  the  inadequate  office  equipment  of  the  pri- 
vate physician  to  whom  they  might  afford  to  go  lessens  their 
chance.  Do  not  principles  of  human  economy  and  economy 
of  resources  apply  here?  We  would  not  for  one  moment 
submit  to  any  abuse  of  the  dispensary  or  hospital  if  we  were 
aware  of  it,  nor  would  we  rob  the  private  physician  of  any 
practice  that  rightly  belongs  to  him,  but  it  does  seem  that 
human  rights  may  claim  as  much  as  unscrupulous,  selfish 
doctors. 

The  economic  resources  of  the  communtity  should  be  a 
matter  of  much  concern.  All  that  has  been  said  about  human 
economy  applies  to  this  part  of  the  subject,  for  adequate 
treatment  saves  time,  and  time  in  the  hospital  costs  money. 
Every  man  of  good  earning  capacity  helps  to  circulate  money, 
and  every  one  who  is  equal  to  his  task  is  worth  money  to  his 
employer.  Compare  the  ablebodied,  efficient  workman  with 
the  shiftless,  broken,  incapable  class  that  is  shipped  about 
the  country  for  cheap  labor  purposes  and  employed  by  big 
corporations  in  construction  work.  They  are  a  burden  to 
every  community  they  enter,  either  in  the  police  courts, 
almshouses,  hospitals,  or  relief  agencies,  and  they  contribute 
nothing  to  the  business,  as  they  have  no  money  to  spend. 


JOHN   R.  73 

The  case  of  "John  R."  shows  how  one  of  these  undesirable 
floaters  was  returned  to  his  own  people  and  the  community 
was  spared  the  burden  of  his  support. 

JOHN  R. 

John  R.,  age  thirty-one,  U.  S.,  address  European  Rooming 
House,  laborer,  not  working  now;  physical  defects,  right  arm 
amputated,  apparently  feebleminded. 

The  patient  applied  at  the  Out-patient  Department  for 
treatment  of  an  axillary  abscess.  This  was  taken  care  of,  and 
he  was  discharged  as  cured  in  a  week.  Although  the  medical 
service  rendered  was  very  small  because  the  need  was  slight,  a 
complicated  problem  was  opened  up  which  called  for  intensive 
social  work.  The  record  reads  as  follows: 

Sept.  3/15.  Patient  was  very  dirty  when  he  came  to  the 
dispensary  for  treatment,  calling  forth  a  protest  from  the 
doctor  who  attended  him.  As  he  was  staying  at  a  cheap 
lodging  house,  without  proper  facilities  for  a  bath,  he  was 
given  a  card  to  a  settlement  house  in  the  neighborhood  for  a 
bath.  Clean  clothing  was  provided  also. 

Sept.  5/15.  Patient  returned  to  the  Out-patient  Depart- 
ment for  surgical  dressing.  He  looked  much  improved  and 
expressed  gratitude  for  the  favor.  Something  in  the  man  gave 
the  impression  that  there  must  be  some  refinement  back  of 
his  feebleminded,  unkempt  condition,  and  inquiry  was  made 
about  his  home.  Handicapped  as  he  is,  it  is  going  to  be  dif- 
ficult for  him  to  support  himself,  and  he  will  be  likely  to  fall  a 
prey  to  unscrupulous  persons  who  will  take  advantage  of  his 
feeble  mind.  He  gave  a  very  accurate  address  of  an  aunt  in 
the  East,  and  a  letter  was  written  to  her  at  once,  stating  his 
circumstances,  and  asking  if  there  were  some  relatives  that 
could  come  and  take  him  where  he  might  have  the  protection 
he  needed. 

Sept.  12/15.  Reply  was  received  from  the  aunt,  saying 
that  John  had  two  sisters  and  a  brother  whom  she  was  writing 
to  the  same  day,  and  she  was  sure  they  would  send  money  for 
his  return  home.  They  had  been  trying  to  locate  the  boy  for 
some  time,  but  had  failed,  and  were  indeed  glad  to  know  of  his 


74  "THE  HOSPITAL  AS  A  SOCIAL  AGENT" 

whereabouts.  Call  made  on  this  date  upon  a  Mr.  V.,  who 
keeps  a  lodging-house  across  the  street  from  the  one  where 
John  is  staying.  As  we  knew  that  Mr.  V.  would  co-operate 
with  us  in  the  case,  we  asked  him  to  get  John  over  to  his  place 
that  he  might  help  to  keep  track  of  John,  and  whatever  ex- 
pense was  incurred  for  his  board  would  be  met  when  the  family 
were  again  heard  from. 

Sept.  13/15.  Mr.  V.  telephoned  that  John  would  not 
change  his  boarding  place,  as  he  preferred  to  stay  where  he 
was.  He  says  certain  lawyers  have  his  case  to  try  and  get  a 
settlement  from  the  railroad  for  the  loss  of  his  arm.  They  are 
paying  him  $5.00  a  week  while  he  is  waiting,  and  say  they  have 
sued  for  $50,000.  John  expects  to  get  one-half  when  the 
claim  is  settled,  so  he  is  much  elated  at  the  prospect. 

Sept.  29/15.  Letter  received  from  the  sister  in  the  West, 
enclosing  one  for  John  and  $30  to  be  used  for  his  expenses 
home.  John  visited  the  hospital,  and  his  letter  was  given  to 
him,  but  the  money  was  left  with  the  social  worker  until  he  is 
ready  to  go. 

Oct.  5/15.  John's  uncle  from  the  East  came  to  see  what 
was  best  to  do  with  him,  as  the  family  did  not  wish  to  have  him 
roaming  about  the  country.  The  uncle  seems  to  be  a  kind- 
hearted,  good,  intelligent  man,  and  says  that  John  has  lived  at 
his  house  much  of  the  time  since  his  mother  died.  He  has  a 
roving  disposition  and  will  not  stay  at  home,  although  they 
have  done  everything  they  could  to  hold  him.  For  months  at 
a  time  they  would  not  know  anything  of  him,  and  he  has  not 
been  home  now  for  about  three  years. 

Oct.  7/15.  The  uncle  returned  to  his  home.  In  the  two 
days  of  his  stay  he  called  on  the  claim  agent  of  the  railroad 
and  also  the  lawyers.  The  claim  agent  said  John  was  a 
trespasser,  and  so  they  were  in  no  way  responsible  for  his 
treatment,  but  they  had  paid  the  hospital  bill,  gotten  him  a 
new  suit  of  clothes,  and  given  him  $10  for  his  ticket  home. 
Nothing  else  could  be  expected  of  them.  The  lawyers  said 
they  were  hopeful  of  getting  a  settlement,  that  they  had  many 
such  cases  on  their  list,  and  were  very  successful  with  them. 
They  wanted  John  to  stay  in  town  until  the  case  came  up  in 
court,  and  they  were  willing  to  pay  his  expenses  in  the  mean- 


JOHN  R.  75 

time.  While  in  the  lawyers'  office  John  came  in,  and  the  uncle 
was  much  shocked  to  see  how  changed  he  was.  His  mental 
state  was  much  weaker  than  when  he  last  saw  him.  John  was 
a  patient  in  the  Texas  State  Hospital  a  few  years  ago,  and  he 
has  been  wandering  about  since  he  was  released  from  there. 
The  uncle  talked  with  him  in  a  confidential  way,  and  found 
that  he  had  delusions  and  hallucinations,  and  he  felt  that  it 
would  be  difficult  to  care  for  him  at  home.  If  possible  to 
accomplish  it  State  Hospital  care  was  best  for  him.  Not 
wishing  to  take  the  responsibility  himself,  he  telegraphed  to 
his  sister,  asking  if  she  would  advise  placing  him  in  a  hospital 
for  the  insane.  She  replied  she  wished  the  uncle  to  use  his 
judgment  in  the  matter.  He  called  upon  the  Probate  Judge, 
to  ask  if  he  would  commit  John  to  a  hospital  in  this  state, 
but  he  said  John's  legal  residence  was  not  here  and  he  should 
go  to  his  home  to  be  committed.  As  the  laws  of  the  other 
state  would  not  permit  a  relative  to  bring  a  patient  back  for 
the  purpose  of  committing  him,  the  judge  advised  leaving  him 
until  the  lawyers  had  finished  with  his  case.  It  might  work 
against  his  chances  for  a  settlement  to  declare  him  insane. 
With  these  facts  in  consideration,  the  uncle  thought  best  to 
go  back  and  leave  John's  case  in  the  hands  of  the  social  worker 
to  complete  as  matters  developed. 

Nov.  12/15.  John  reported  that  the  lawyers  had  not  suc- 
ceeded in  getting  his  case  brought  into  court,  and  as  it  might 
be  some  time  before  they  would  accomplish  anything  they 
thought  he  had  better  go  to  his  home,  and  they  would  send  for 
him  if  it  did  come  up.  John  is  willing  to  go  and  wants  to  start 
at  once. 

Nov.  13/15.  Bought  railroad  ticket  and  wrote  out  direc- 
tions for  changes  of  cars,  etc.,  and  arranged  with  Mr.  V.  to 
put  John  on  the  train,  giving  him  a  small  amount  of  change  for 
meals.  Telegraphed  the  uncle  when  he  would  arrive  home, 
and  sent  balance  of  sister's  money  by  mail. 

Nov.  17/15.  Received  letter,  saying  that  John  had  arrived 
home,  and  that  they  would  keep  him  there  until  they  could 
decide  what  was  best  to  do  with  him. 

A  year  later  learned  that  John  had  been  at  his  uncle's 
or  his  brother's  ever  since  he  left  here,  and  he  was  getting  along 


76  "  THE  HOSPITAL  AS  A  SOCIAL  AGENT  " 

pretty  well,  but  they  could  see  he  was  failing  mentally.  Before 
leaving  for  home  he  started  to  drinking  quite  heavily  and  took 
no  care  of  himself,  seeming  to  desire  nothing  but  a  mere 
existence,  so  he  was  a  pitiful  specimen  when  he  was  put  on  the 
train.  The  uncle,  having  seen  him,  and  knowing  how  unkempt 
he  was,  desired  to  save  the  family  the  shock  of  his  appearance, 
so  he  met  him  at  the  train  and  had  him  cleaned  up  before 
taking  him  home. 

There  are  some  undesirable  persons  that  can  never  be 
made  to  take  their  place  in  the  world,  but  there  are  others 
that  may  be  helped  to  become  self-sustaining  and  relieve 
the  community  of  the  burden  of  their  support.  If  municipal 
and  county  authorities  could  appreciate  these  economic 
values,  they  would  then  become  helpful  social  agents,  and 
money  spent  for  useless  individuals  might  be  saved  for  those 
who  are  beyond  working  ability  or  who  are  accidentally  help- 
less. These  officials  would  profit  by  securing  the  service  of  a 
competent,  experienced  social  worker,  who  would  help  to 
give  them  a  social  vision  which  they  are  incapable  of  because 
of  the  blinding  effects  of  politics  or  greed  of  gain.  How  use- 
less to  support  a  young  fellow  indefinitely  in  the  county  home, 
who  is  unfortunately  crippled  by  a  double  amputation,  in- 
stead of  spending  $200  to  secure  artificial  limbs  and  fit  him 
for  some  place  in  the  world.  With  a  social  worker  to  adjust 
him  to  his  work  and  to  his  place,  he  may  be  transformed  from  a 
useless  dependent  to  a  self-respecting  citizen,  capable  of  his 
own  support.  From  the  standpoint  of  the  saving  of  money 
it  is  a  simple  problem  in  arithmetic,  counting  the  man's  board 
in  the  home  at  $15  a  month,  in  one  year  he  would  cost  the 
county  $180,  almost  as  much  as  the  artificial  limbs.  Multi- 
plying this  amount  by  forty  years,  which  would  complete 
the  average  life,  one  can  readily  appreciate  the  fact  that  public 
funds  are  expended  to  no  purpose  except  to  keep  the  man  alive. 


ECONOMY  OF   RESOURCES  77 

The  loss  of  service  to  the  world,  and  the  injustice  to  the  young 
man  by  depriving  him  of  his  ambition  and  opportunity,  is 
also  a  serious  consideration. 

Social  workers  are  well  aware  of  the  disadvantages  arising 
from  the  lack  of  appreciation  of  the  real  social  needs  of  the 
indigent  poor  by  public  officials  in  town  and  county.  The 
proper  solution  of  a  social  problem  may  require  the  assistance 
of  one  of  these  agencies,  but  there  is  often  great  difficulty  in 
getting  them  to  understand  the  value  of  real  adequate  treat- 
ment, and,  as  there  are  no  other  means  at  hand,  workers  are 
at  a  loss  to  know  what  to  do.  These  officials  are  prone  to 
employ  incompetent  persons  for  positions  where  experts 
alone  should  be  placed.  While  larger  salaries  must  be  paid 
to  secure  such  competent  help,  money  would  be  saved  by 
shortening  the  period  in  which  the  individual  might  be  de- 
pendent. The  most  efficient  service  is  the  most  economic 
all  around. 

True,  the  indigent  class  of  people  are  very  unsatisfactory 
to  deal  with,  but  the  community  demands  proper  handling 
for  its  own  protection,  and  do  not  these  people  with  their  social 
problems  properly  belong  to  public  agencies?  Then  why 
should  not  the  tax-payers  insist  upon  the  most  economic, 
practical,  efficient  expenditure  of  the  public  funds  for  the  care 
of  its  indigent,  dependent  members,  both  for  the  sake  of  the 
individuals  themselves  and  for  all  who  make  up  the  community? 

This  question  of  human  economy  and  economy  of  re- 
sources then  should  enter  into  the  solution  of  all  our  social 
problems.  Any  slipshod  way,  or  the  one  which  follows  the 
lines  of  least  resistance,  is  an  injustice  to  all  concerned;  in- 
deed, it  is  almost  a  crime  against  humanity.  No  case  should 
be  taken  care  of  without  the  ultimate  good  in  mind,  and  in 
these  days  of  experience  and  research  there  is  no  excuse  for 
any  social  work  which  is  not  as  scientific  as  medical  work. 


78        "  THE  HOSPITAL  AS  A  SOCIAL  AGENT  " 

The  wonderfully  scientific  work  which  has  been  done  in 
France  in  the  treatment  of  wounded  soldiers  illustrates  in  a 
remarkable  degree  the  principles  of  economy.  The  work  is 
medical,  but  it  is  also  social  service.  The  whole  plan  of  organ- 
ization is  based  upon  the  economy  of  the  lives  of  the  soldiers, 
of  their  vitality,  and  the  economy  of  time  and  money.  There 
must  needs  be  as  many  men  saved  and  returned  to  their 
places  in  the  army  as  possible,  and  medical  experts  have  stud- 
ied to  find  a  method  of  treatment  which  would  conserve 
vitality  by  hastening  repair.  Prophylactic  measures  are  used 
as  soon  as  men  are  brought  wounded  from  the  battlefield 
without  waiting  for  the  hospital  to  be  reached,  and  many 
lives  have  been  saved  through  this  one  precaution.  Again, 
those  who  are  maimed  beyond  complete  repair,  receive  the 
most  skilful  attention  to  produce  the  best  possible  results 
that  utter  helplessness  may  not  be  their  lot  the  rest  of  their 
lives.  Here  is  a  social  and  a  medical  service  to  the  whole 
world  as  well  as  to  individuals,  and  it  should  be  a  lesson  in 
economics  to  all  social  workers,  but  especially  to  those  engaged 
in  hospital  work. 


CHAPTER  VIII 

THE  PLACE  OF  THE  HOSPITAL  IN  PUBLIC] 
HEALTH  WORK 

THE  latent  possibilities  of  hospital  social  service  lie  in  the 
important  aid  which  may  be  given  to  public  health  work. 
Both  the  immediate  community  and  the  state  have  or  should 
have  comprehensive  programs  for  public  health  work,  and 
the  hospital  should  be  included  among  the  co-operating 
agencies. 

Public  health  must  be  promoted  by  the  efforts  and  co- 
operation of  every  member  of  the  community.  If  one  man 
suffering  from  tuberculosis  spits  on  the  sidewalk  he  endangers 
every  other  person  in  the  community,  but  if  every  person  re- 
frains from  spitting,  no  one  is  put  in  danger  from  this  source. 
The  question  resolves  itself  then  into  a  matter  of  educating  the 
public  to  avoid  the  sources  of  danger.  That  part  of  the  public 
which  does  not  wilfully  recognize  danger,  must  be  forced  to 
observe  certain  laws  for  the  protection  of  all.  Thus  it  has 
become  necessary  to  make  laws  prohibiting  spitting.  The 
people  of  the  United  States  have  sometimes  misconstrued 
the  idea  of  freedom  to  mean,  that  if  I  wish  to  throw  my 
garbage  over  the  fence  I  am  permitted  to  do  it,  so  long  as  it 
does  not  annoy  me  nor  my  family  and  if  it  saves  me  trouble 
and  expense.  I  am  the  one,  as  well  as  my  neighbor  who  is 
ignorant  of  the  danger  there  is  in  my  open  garbage  and  his 
uncovered  manure  pile,  for  whom  public  health  laws  are  made 
and  enforced. 

79 


8o  "THE  HOSPITAL  AS  A  SOCIAL  AGENT" 

Not  only  must  we  educate  people,  either  willingly  or  for- 
cibly, but  we  must  provide  adequate  means  and  facilities 
for  the  care  of  communicable  diseases  or  those  which  are  the 
result  of  unsanitary  surroundings,  and  see  that  health  offi- 
cials enforce  the  laws  which  eliminate  and  regulate  all  possible 
sources  of  danger  to  the  health  of  the  community.  Adequate 
means  and  facilities  for  the  care  of  disease  include  sufficient 
hospital  beds,  and  proper  equipment  to  take  care  of  tuber- 
culous patients  and  those  suffering  from  all  contagious  and 
specific  diseases.  Unless  a  community  can  properly  take  care 
of  those  who  are  sick  from  these  ailments,  it  cannot  expect 
to  stop  the  progress  of  disease  nor  to  effectively  educate  the 
public  to  its  danger  and  to  the  necessity  of  medical  care. 

Another  feature  is  important,  that  of  careful  examination 
and  diagnosis,  and  the  detection  of  disease  in  its  beginning 
stage.  This  is  where  the  hospital  and  dispensary  can  aid  so 
efficiently  in  Public  Health  Work,  for  its  equipment  is  com- 
plete and  its  medical  service  equal  to  the  demand.  Differ- 
entiation in  diagnosis  can  be  more  easily  determined,  and  the 
social  worker  is  able  to  direct  her  efforts  in  the  right  direction. 
This  is  especially  true  with  venereal  diseases  and  tubercu- 
losis. Those  needing  special  hospital  care  are  placed  where 
they  can  be  treated;  those  who  may  be  taken  care  of  in  the 
homes  and  treated  by  dispensary  physicians  can  be  followed 
up  with  evident  benefit;  those  who  are  beyond  help  may 
have  medical  and  social  treatment  directed  toward  the  com- 
fort of  the  patient  or  his  removal  to  a  place  of  safety  for 
others  of  his  household. 

DAVID,  A  TUBERCULOUS  PATIENT 

David,  age  seventeen;  single;  born  U.  S. 
Feb.  7/14.    Patient  referred  from  the  Out-patient  Depart- 
ment to  the  hospital,  quite  sick  with  pleurisy.     Investigation 


Fig.  12. — A  breeding  place  for  physical  and  moral  disease. 


Fig.  13. — The  little  girl  on  the  extreme  left  is  already  showing  the  truth  of 
Jack  London's  saying. 


DAVID,    A    TUBERCULOUS    PATIENT  8 1 

shows  that  he  and  his  sister,  nineteen  years  old,  live  with  and 
support  their  grandmother,  who  has  raised  them  from  child- 
hood. The  sister  is  a  typewriter,  working  in  a  company 
office,  earning  $35  a  month.  The  patient  has  been  making 
$10  a  week  for  a  short  time,  driving  for  a  grocery  store.  The 
family  pays  $15  for  three  rooms  in  a  flat,  without  heat  or  light. 
The  boy  has  been  sick  three,  weeks,  consulting  a  doctor  but 
once  before  coming  to  the  Out-patient  Department.  Examina- 
tion in  the  dispensary  showed  pleurisy  with  effusion  and  prob- 
ably pulmonary  tuberculosis.  Called  David's  sister  by  tele- 
phone to  tell  her  that  he  was  admitted  to  the  hospital,  so  she 
might  explain  to  the  grandmother.  She  came  to  the  hospital 
to  see  the  social  worker,  who  told  her  the  nature  of  David's 
trouble,  and  what  might  be  necessary  for  him  when  he  was 
ready  to  leave  the  hospital. 

Feb.  9/14.  Visited  the  home  and  saw  the  grandmother. 
She  fears  that  they  must  move  into  cheaper  rooms  if  David  is 
ill  and  unable  to  contribute  to  the  support  of  the  family,  but  she 
will  do  the  best  that  she  can.  The  family  being  Catholic,  the 
case  was  reported  to  the  St.  Vincent  de  Paul  Society  for  as- 
sistance if  it  became  necessary. 

Feb.  21/14.  Visitor  from  the  St.  Vincent  de  Paul  Society 
called  to  say  that  they  had  no  funds  to  pay  for  David  at  a 
sanatorium,  if  it  seemed  best  to  send  him  there,  but  they  would 
be  glad  to  give  the  family  relief  if  that  was  necessary. 

Feb.  25/14.  The  attending  physician  on  the  ward  reports 
the  condition  of  the  patient  so  favorable  that  he  thinks  it  will 
not  be  necessary  for  him  to  go  to  a  sanatorium.  As  he  has  an 
uncle  on  a  ranch  in  Montana,  he  thinks  he  may  be  able  to 
arrange  to  go  oat  there  to  recuperate.  This  plan  is  approved 
by  the  doctor,  when  the  weather  is  favorable  and  the  patient's 
strength  will  permit. 

Feb.  26/14.  Saw  sister  and  talked  over  the  plan  with  her, 
and  asked  if  David  could  be  cared  for  properly  at  home  until  he 
was  able  to  go  away.  She  said  she  thought  he  could,  and  that 
she  would  write  at  once  to  the  uncle,  so  as  to  start  preparations 
for  the  trip. 

March  1/14.  Visited  the  home  and  talked  over  necessary 
arrangements  for  the  home  care.  Find  that  he  can  have  the 

6 


82         "  THE  HOSPITAL  AS  A  SOCIAL  AGENT  " 

exclusive  use  of  the  front  room,  where  fresh  air  can  be  obtained 
day  and  night.  Gave  instructions  as  to  the  importance  of 
fresh  air  and  proper  food  and  necessary  precautions  to  take. 

March  14/14.  Patient  was  discharged  from  the  hospital 
and  went  home.  Ordered  1  quart  of  milk  and  \  dozen  eggs 
sent  every  day,  and  had  same  charged  to  the  Antituberculosis 
Society,  by  their  order.  He  is  to  report  to  the  dispensary 
twice  a  week  for  observation. 

April  2/14.  Visited  patient  in  his  home,  and  found  him  in 
splendid  condition;  he  has  gained  10  pounds  since  leaving  the 
hospital.  He  has  heard  from  his  uncle  in  Montana,  who  sent 
him  the  money  for  railroad  fare,  and  he  will  let  him  know  as 
soon  as  the  weather  is  warm  enough  out  there  for  him. 

April  11/14.  Patient  returned  to  the  Out-patient  Depart- 
ment with  a  return  of  pleurisy,  and  the  doctor  referred  him  to 
the  hospital  wards  again.  His  condition  at  this  time  seems 
to  point  more  decidedly  to  a  tubercular  involvement,  and  the 
doctor  advises  a  short  stay  at  the  sanatorium  before  starting  to 
Montana.  It  was  then  necessary  to  find  some  means  to  pay 
the  $5  a  week  fee  at  the  sanatorium.  This  was  obtained 
($30)  from  the  "Fellowship  Fund"  in  one  of  the  Protestant 
churches. 

May  16/14.  Patient  transferred  to  the  sanatorium  by  his 
sister,  she  furnishing  the  money  for  the  trip. 

July  11/14.  Patient  returned  from  the  sanatorium,  very 
much  improved,  having  gained  20  pounds  in  weight,  and  looking 
rugged  and  well.  He  made  good  progress  during  his  stay,  and 
the  doctor's  judgment  is  that  his  is  an  arrested  case,  which  will 
do  well  in  right  surroundings. 

July  18/14.  Patient  started  for  Montana,  very  happy  and 
grateful  for  all  that  had  been  done  for  him.  Before  leaving  a 
visit  was  made  to  the  pastor's  study  at  the  church  which  had 
furnished  the  money  for  sanatorium  fees,  in  order  to  thank  the 
minister  in  person  for  the  aid  which  had  been  given. 

Nov.  10/14.  The  following  letter  was  received  by  the 
social  worker  which  will  speak  for  itself: 

"Dear  Miss  C.:  I'm  sending  you  a  few  lines  to  tell  you 
how  I  am.  I  feel  fine  out  here,  the  air  is  fine,  and  I  can 
eat  like  a  horse.  I  hope  you  feel  the  same.  Please  excuse 


THE   HOSPITAL   IN   PUBLIC   HEALTH  WORK  83 

me  for  not  writing,  we've  been  branding  calves  and  horses 
and  making  hay  for  winter.  I  got  awfully  strong  out  here, 
I  have  lots  of  fun  riding  horses  and  hunting  wolves  and 
wild  ducks  and  chickens.  I  have  320  acres  of  land 
right  near  my  uncle's  place.  Be  sure  and  write  and  tell  me 
how  yoU  are  and  everything  at  home.  I  lost  the  minister's 
card,  so  do  not  know  his  address,  you  can  send  it  to  me, 
I  like  to  write  him  a  letter.  Well,  goodby,  from  your 
friend, 

DAVID." 

Recognition  should  be  granted  the  hospital  as  a  co-oper- 
ating agent  in  the  program  for  public  health  work,  and  in 
order  to  command  this  service  the  hospital  organization, 
medical  and  social,  must  prove  its  efficiency.  With  this  es- 
tablished, why  should  not  the  dispensary  be  sought  by  city 
and  county  authorities  for  its  examining  agent,  and  a  certain 
amount  of  money  be  appropriated  regularly  for  this  service? 
Would  this  not  be  better,  from  the  standpoint  of  economy, 
than  to  trust  this  important  work  to  incompetent  means 
at  their  disposal?  And  would  not  more  efficient  work  be 
accomplished  for  the  welfare  of  public  health? 

Another  valuable  aid  is  shown,  by  careful  examination 
and  accurate  diagnosis  that  is  possible  in  the  dispensary,  in 
the  detection  of  such  contagious  diseases  as  diphtheria, 
scarlet  fever,  and  small-pox.  Take,  for  example,  the  young 
man  who  arrives  in  the  city  without  money  or  friends,  and, 
feeling  sick,  seeks  the  dispensary  for  the  doctor's  advice. 
General  symptoms,  throat  condition,  laboratory  examination, 
present  unmistakable  evidence  of  diphtheria.  He  cannot  be 
taken  into  the  hospital  that  has  no  contagious  ward,  nor  is 
it  just  to  him  or  to  others  to  send  him  out  on  the  streets, 
knowing  he  has  no  home  to  go  to,  nor  any  means  of  obtain- 
ing suitable  care.  A  message  to  the  local  board  of  health, 
whether  or  not  they  have  a  contagious  hospital,  should  be 


84  "THE  HOSPITAL  AS  A  SOCIAL  AGENT" 

all  that  is  necessary  to  obtain  immediate  attention  in  this 
case,  and  it  is  the  only  one  that  should  satisfy  the  public 
mind  for  the  protection  of  every  member  of  the  community. 

Aside  from  the  accurate  diagnosis  of  cases  and  actual 
care  of  patients,  the  dispensary  is  an  important  aid  in  the 
program  of  public  health  work  through  its  value  as  an  edu- 
cational center.  There  is  no  focal  point  more  crucial  than 
this  for  education  in  the  laws  and  principles  of  hygiene  and 
good  health.  Especially  is  this  true  with  tuberculosis  and  ve- 
nereal diseases  and  the  disorders  of  infants  due  to  ignorance 
of  parents.  The  social  worker  makes  special  effort  to  investi- 
gate the  home  surroundings,  discovers  the  unsanitary  condi- 
tions, and  sees  the  unhygienic  ideas  manifested  in  the  symp- 
toms of  the  patient  and  recognizes  the  danger  to  others. 
With  this  intimate  touch  in  the  home,  and  the  vantage  point 
in  the  dispensary,  where  numbers  may  be  gathered  together 
in  classes,  the  benefits  of  teaching  are  enhanced  many  fold. 
Such  splendid  work  may  be  done  by  grouping  the  mothers 
and  babies,  and,  by  means  of  demonstration  and  instruction, 
to  show  the  mothers  the  proper  methods  in  the  care  of  their 
babies  and  the  reasons  why.  A  spirit  of  interest  may  thus 
be  engendered  to  follow  instructions  and  watch  the  results, 
not  only  each  one  in  her  own  baby,  but  in  every  other  child 
that  is  brought  to  the  class.  This  is  a  part  of  the  program  for 
infant  welfare  which  should  form  one  of  the  co-operating 
forces  in  this  line  of  public  health  work. 

The  importance  of  education  in  the  clinics  for  venereal 
diseases  cannot  be  overestimated,  as  we  are  dealing  with  the 
direct  results  of  the  cause  of  the  trouble.  We  are  able  to 
reach  the  very  source  of  the  spread  of  the  disease,  bringing 
special  emphasis  upon  the  dangers  to  present  and  future 
generations,  besides  the  danger  from  direct  contact. 

Illustrative  of  this  is  the  case  of  a  young  girl  seventeen 


I 


.===:_ 
i   -~^  * : 


Jk 


Fig.  15. 

Figs.  14  and  15. — What  can  be  expected  from  children  with  playgrounds  and 
surroundings  like  these? 


THE   HOSPITAL   IN  PUBLIC   HEALTH   WORK  85 

years  old  who  visited  the  dispensfary  for  treatment  of  a  throat 
trouble.  The  specialist  recognized  an  active  case  of  syphilitic 
infection,  which  called  for  prompt  treatment  to  prevent  further 
progress  of  the  disease  and  imminent  danger  to  others.  The 
girl  was  a  nurse  maid  in  a  family  where  there  were  several 
small  children,  one  a  baby  which  was  her  special  care,  and 
whom  she  was  in  the  habit  of  kissing  and  fondling.  Here 
was  a  desperately  critical  situation,  where  not  a  moment 
should  be  lost  in  starting  immediate  medical  and  social  work, 
and  it  is  needless  to  say  the  girl  had  hardly  left  the  dispensary 
before  the  note  of  warning  to  the  mother  of  the  children  in 
the  home  was  sounded  over  the  telephone. 

In  the  prevention  of  the  spread  of  eye  diseases  and  the 
conservation  of  sight  there  is  an  important  co-operative 
work.  Wonderful  results  may  be  obtained  through  home 
investigation  and  instruction  in  prophylaxis  and  hygiene, 
and  in  bringing  about  the  persistent  return  of  the  patient  for 
treatment  until  he  has  been  cured.  Also  in  co-operation 
with  school  nurses  and  teachers,  securing  necessary  glasses 
for  pupils  that  the  sight  may  be  saved,  a  public  service  is 
rendered. 

So  we  might  go  on  elaborating  along  different  lines,  but 
enough  has  been  said  to  expose  the  underlying  principles 
which  the  social  worker  in  any  small  hospital  community  may 
put  into  practice  in  the  development  of  her  department. 
We  feel  sure  that  all  will  agree  that  the  development  of  hos- 
pital social  service  must  be  along  the  lines  of  public  health 
work,  which  is  broadening  out  to  meet  the  demands  of  the 
community  for  protection  against  all  sources  of  danger  to 
the  health  of  its  individuals. 


CONCLUSION 

IN  the  foregoing  chapters  an  endeavor  has  been  made 
to  demonstrate  the  established  work  of  the  hospital  social 
service  department  and  to  show  its  future  possibilities.  The 
hospital  has  always  held  a  most  important  place  in  the  com- 
munity, indispensable  in  its  service  to  suffering  humanity, 
and  winning  its  way  into  the  hearts  of  the  people  through 
increasing  confidence  in  its  work.  Social  service  has  devel- 
oped the  hospital's  value  and  increased  its  usef ulness  '"as  a 
social  agent.  It  has  placed  the  hospital  in  the  forefront  as  an 
important  asset  in  the  welfare  of  the  community  and  of  the 
state. 

Much  stress  has  been  laid  upon  the  service  to  the  indi- 
vidual, to  the  community,  and  to  society,  and  the  reiteration 
may  seem  superfluous  and  tiresome  to  some  degree,  but  its 
great  importance  links  it  so  closely  to  effective,  adequate 
service  that  it  will  bear  frequent  repetition.  ^Individuals 
make  up  the  community,  communities  form  society,  so  what- 
ever good  or  evil  is  in  one  affects  the  others,  and  whatever 
influences  are  brought  to  bear  upon  one  helps  to  make  the 
others.  An  individual  burden  becomes  a  community  burden 
and  individual  economy  is  a  community  benefit.  These  are 
things  that  science  teaches  us.  Social  work  has  become  scien- 
tific in  as  great  a  degree  as  medical  work,  for  it  deals  with  the 
whole  man — his  physical  condition,  his  aspirations,  his  pas- 
sions, his  work,  his  place  in  the  world.  Sickness  is  often  the 
adversity  which  changes  the  life  and  purpose  of  the  man; 
it  sometimes  forces  him  into  entirely  different  channels, 

86 


CONCLUSION  87 

where  new  adjustments  are  necessary.  "The  study  of  char- 
acter under  adversity  is  the  essence  and  center  of  social 
work."  Opportunities  for  great  service,  therefore,  come  to 
hospital  workers  and  make  the  obligations  to  the  community 
most  profound. 

Social  service  is  not  new  in  its  conception  or  operation. 
It  is  but  the  scientific  development  of  what  was  formerly 
called  "charity  work."  Yet  there  existed  in  the  minds  of  the 
charity  workers  years  ago  the  essential  principles  of  most 
effective  social  service.  Because  of  the  voluntary  element 
organization  was  incomplete,  and  facilities  which  are  at  hand 
today  were  not  available  for  the  proper  conduct  of  case  work 
then.  Illustrious  examples  of  volunteer  workers  remain  in 
the  memory  of  beneficiaries  never  to  be  erased,  and  these 
workers  are  the  ones  who  have  laid  the  foundations  for  the 
present  scientific  system.  While  hospital  social  service  is 
one  of  the  new  developments,  it  is  really  only  the  application 
of  old,  tried  principles  to  the  needs  of  hospital  work. 

The  inspiration  for  this  book  came  from  long  association 
with  one  who  was  a  leader  in  many  benevolent  enterprises 
thirty  or  forty  years  ago.  She  worked  out  social  problems 
with  a  wonderful  insight  into  the  causes  of  social  maladjust- 
ment, and  broad  ideas  of  reconstruction.  Yet  her  days  of 
active  duty  were  over  before  the  hospital  child  was  scarcely 
out  of  its  swaddling  clothes.  It  was  her  love  of  humanity 
and  her  sympathy  for  people  to  whom  adversity  came,  and 
her  service  which  was  actuated  by  a  Christ-like  spirit,  that 
produced  the  far-reaching  results  whose  influence  is  still 
felt  in  the  community  where  she  lived  and  worked. 

We  can  scarcely  conceive  of  a  successful  social  worker 
in  the  hospital  whose  life  is  not  dominated  by  the  love  and 
spirit  of  Christ.  The  hospital  has  always  been  a  sacred  in- 
stitution. The  first  one  was  established  by  the  Good  Samar- 


88  "THE  HOSPITAL  AS  A  SOCIAL  AGENT" 

itan  when  he  found  the  wounded  man,  placed  him  on  his 
own  beast,  and  took  him  to  an  inn.  We  are  told  he  took  care 
of  him,  and  in  the  morning  when  he  departed  he  endowed 
the  first  hospital  ward  for  this  patient.  Thus,  what  we  now 
call  social  service  was  made  complete  in  this  case,  and  Jesus 
said  to  the  lawyer  whose  question  called  forth  the  parable, 
"Go,  and  do  thou  likewise." 


APPENDIX 

FACSIMILES  of  the  different  forms  of  blanks  used  in  the 
Social  Service  and  Out-patient  Departments  of  the  Youngs- 
town  Hospital  are  here  appended  for  the  purpose  of  suggest- 
ing to  those  who  are  seeking  help  a  plan  of  record  keeping 
which  has  been  worked  out  and  found  to  be  complete  and 
yet  simple. 

The  matter  of  records  is  most  important.  Social  histories 
which  exist  in  the  memories  of  workers  are  utterly  valueless, 
yet  it  is  many  times  a  question  with  busy  workers  whether 
to  sacrifice  the  social  work  or  the  records.  History  taking 
and  record  keeping  then  resolves  itself  into  a  matter  of  pro- 
viding blanks  that  are  simple  but  comprehensive,  and  of 
developing  an  indexing  and  filing  system  so  easily  understood 
that  the  recordls  are  available  to  any  hospital  official  seeking 
information. 

Reference  blanks  are  of  the  greatest  value,  as  they  work 
automatically  in  carrying  out  the  system  for  the  proper  care 
of  the  patient,  and  help  to  complete  the  records.  This  is 
shown  in  the  set  of  cards  and  blanks  which  take  the  patient, 
Annie  Yorchek,  from  her  admission  to  the  out-patient  depart- 
ment, through  the  hospital,  back  to  the  out-patient  depart- 
ment again. 

Record  keeping  should  be  so  planned  that  a  complete 
history  of  a  case  may  be  made  with  the  greatest  conserva- 
tion of  time  and  energy  on  the  part  of  the  worker.  The  plan 
should  also  be  perfect  enough  to  furnish  accurate  information 
of  the  medical  and  social  status  of  the  patient,  and  the  full 

89 


"  THE  HOSPITAL  AS 


record  should  be  filed  in  one  envelope  or  holder  with  all  cor- 
respondence or  papers  which  pertain  to  the  case. 

Some  of  the  blanks  in  the  facsimiles  have  been  filled  out 
to  demonstrate  their  use,  while  others  are  self-explanatory. 


*  S9 

0 #     '  ^f 

Jf  ^C  ^t  .^- -^a    *    .         S 


,    I     (~ 


Hospital  No.  //d-7     $     X*"     Ward        Q,  .  Service 


Nationality    V^f/^.V^T    Yf».  U.  S.  ^/,   %I          a«jr 


Fig.  16. — Hospital  Social  Service  case,  short  history  form.  This  card 
combines  the  case  history  and  index  card,  and  shortens  the  process  of  history 
taking  and  filing.  The  name,  address,  hospital  number,  ward,  service,  and 
date  of  admission  is  obtained  from  the  hospital  admission  blank,  and  the 
card  is  taken  to  the  bedside  of  the  patient  for  the  record  of  the  social  history. 
If  no  special  work  is  necessary  for  the  patient,  all  that  is  required  to  complete 
the  record  when  he  is  discharged  is  the  diagnosis,  discharge  date,  and  a 
statement  of  the  disposition  of  the  case.  This  card  is  then  filed  with  the 
other  index  cards,  and  its  face  shows  it  to  be  a  short  history  case. 


APPENDIX 


-QC 


*H££4, 


^Mfe^xl 


4-<ft 


^ 


.«£ 


Q^ix.^.X 


t-^  •  j 

^^^dUL^ 


d?.A.A 


>    ^>/-7^ 
fo  J*,Zt 


31  SV.Sl*2  .    .A.C^^lv^,/   X^., 

,S\^Lf  tq£Zo-^~&»"    U»    w«^       tf.^-^C/^r 

^^  *  -  ^         • 


x  r 

faJ* 

- 


Fig.  17. — Reverse  side  of  history  case  card. 


92  "THE  HOSPITAL  AS  A  SOCIAL  AGENT " 

The  Youngstown  Hospital  Association 

Social  Service  Department 


Hospital  No. 
34345 

Name 
p|fT/V^      HOSIW 

S.  S.  Dept  No. 

Address 

jr  St 

Service 
Obat. 

Ward 

a 

Admitted 
1/^1  /1*» 

Discharged                 Age 

a  A  3/1  5           94 

Nationality                Years  in  U.  S. 

Hnncr                                     *7 

City 

a 

Religion  Pastor 

HungnrUn  ffftfnrmpfl  -  Rew.Panlfft 


Diagnosis 


History,  etc. 
.Tnn.31.lQlR.    pft+.1flTit.    pr»ngftnt.art    ha^oalf   at 


mission  for  her  confinement.  The  case  was  referred  to  the  S.S.Dcpt. 
to  obtain  social  history  before  admitting  her.  Her  story  was  that 
her  husband  was  not  good  to  her,  that  ha  swore  and  abused  her,  and 
she  wished  to  escape  these  troubles  when  she  was  sick.   There  was  no 
one  to  care  for  her  at  her  home,  and  she  felt  she  would  soon  be  sick. 
Her  husband  works  at  the  Steel  Hills,  and  they  live  in  a  part  of  her 
husband's  father's  house.    As  she  was  a  member  of  Rev.Panko's  Church 
called  him  by  'phone  to  ask  if  he  Jknew  of  the  woman  and  her  troubles* 
He  cane  to  the  Hospital  and  saw  hor,  listened  to  her  story,  and  said 
it  was  no  doubt  true  what  she  said  about  his  abuse,  and  that  her  sad 
face  told  the  story.   These  facts  were  corroborated  by  a  patient  In 
the  ward  and  her  husband,  as  they  knew  her.    The  doctor's  examina- 
tion showed  a  probable  wait  of  two  weeks  longer,  but  as  the  weather 
was  moat  severe  outside,  and  her  husband  bad  driven  her  from  home  the 
night  before,  she  was  admitted,  after  consulting  the  superintendent. 
Feb.  Z.I  91  5.  Patient  was  confined  early  this  morning. 
Feb.  13.  1915.  Patient's  husband  took  her  home.   The  minister  had  talk- 
ed with  him  and  prepared  the  way  for  the  home-coming. 

Fig.  18.  —  Hospital  Social  Service  case  history  form.  This  record 
is  used  in  cases  where  more  intensive  work  is  done,  or  the  nature  of  the  case 
needs  a  fuller  record  of  the  facts. 


BALOa,  ROSIE  #538 

114  Center  St.. 


Fig.  19. — Index  card  for  Hospital  Social  Service  case. 


The  Youngstown  Hospital  Association 

SlfcHARlTlES  Out-patient  Department 
HUMANE  SOC.  Sodal  Hist0fy  and  Record 
V.N.A. 


10      9 


77T 


Length  VTimera     ^ 
State          ~"       U.S. 


Boardert  oc  Other  Income 


Otto  Dcrendenu 


No.ChfldrenHomc 


No.  Married  Total  Children 


-r 


C.O.  S. 

/  ^ 

Fig.  20. — Out-patient  Department  Social  History  case  form.  The  so- 
cial history  of  each  applicant  for  medical  treatment  is  taken  on  this  blank, 
and  the  eligibility  of  the  patient  for  admission  is  based  upon  this  history. 
Any  necessary  investigation  of  the  case  is  subsequently  made,  and  if  inten- 
sive social  work  is  done,  a  record  is  written  on  the  reverse  side  of  the  blank. 


THE  YOUNGSTOWN  HOSPITAL  ASSOCIATION 

0.  P.  D. 


•^ 


A,. 


T — * — 7 — r 


Nationality 


Fig.  21. — Out-patient  Department  index  card.     This  is  pink  in  color,  to 
distinguish  it  from  the  Hospital  case  form,  which  is  white. 

93 


94  "THE  HOSPITAL  AS  A  SOCIAL  AGENT 


<-;LA9g            O^r* 

-  V  /  7  f 

OUT-PATIENT 
YOUNGSTOW 

/    v    f    f 

DEPARTMENT 

N      HOSPITAL 

THREATMENT  FREE;  TO  THE  WORTHY  POOR 

ISJAMP      ^-^v    J*~>*L^S*^£^ 

>^  ^»y  .    /  V                        ^r»  > 

INMIVIC.  *«y.y^  v^vy  ^  **"V  v  1   ir'+^r  *^r  v**^  i*r 

IS^              SURNAME                                                        y»RST    NAME 
OPE^2:3O  TO   3:30   DAILY.    EXCEPT  SUNDAYS  AND   HOLIDAYS 

Fig.  22.  —  Patient's  admission  card 

This  is  linen  and  white  in  color. 

NOTICE 


Bring  this  card  each  day.    It  you  lose  or  fail  to  bring  this  card 
you  will  be  charged  5c  for  another. 


Mefe  &arie  iagUd)  mit* 
fefte  ^etUeten  obcr  nid)t  mftbringcn.  muffen^ie  5  (ScntS 
fur  eine  anbcrc 


Portate  qui  questa  cartolina  ogni  giorno.    In  caso  non  lo  fate 
o  la  cartolina  e  persa  dovrete  pagare  5c. 


a  .05  VI^K  tonD  ^y^yna  w  n  Doynys  nyitj  n»p  yryn 


Fig.  23. — Reverse  side  of  admission  card. 


APPENDIX  95 


39-37718 

The  Youngstown  Hospital  Association 

Out  Patient  Department,  Oak  Hill  Avenue 
Hours  10:00  to  11:00  a.m.  daily  except  Sundays  and  Holidays 


Address 
Referred  b\ 


Clinic  List  Other  Side 


Fig.  24. — Reference  card  for  outside  agencies. 


CLINICS 

General  Medical,  Every  Week  Day. 

General  Surgical,  Every  Week  Day. 

Genito-urinary,   Every  Week  Day. 
Eye  and  Ear,  Monday,  Wednesday  and  Friday. 

Nose  and  Throat,  Monday,  Wednesday  and  Friday. 
Obstetrical,   Friday  Only 

Orthopedic,  Tuesday  and  Saturday 
Dental,  Every  Week  Day. 

Fig.  25. — Reverse  side  of  reference  card. 


THE  HOSPITAL  AS  A  SOCIAL  AGENT 


PATIENT'S  CHECK 

Take  this  to  Druggist  to  be  stamped  be- 
fore leaving. 

Youngstown  Hospital  Association 
Out-Patient  Department 

Treatment  Free  to  the  Poor 
Medicines  and  Supplies  at  Nominal  Prices 

Amount 

Supplies  Furnished 

Price 

Prescriptions^ 

Dressings 

Silver  Irrigations.... 
Mercury  Injection 



No.  Supplies  Fur. 
Total  

x 

M.  D. 

Supplies  furnished  must  be  indicated  above  and 
signed  by  physician  before  patient  will  be  passed  out 

PASS  CHECK 
Date                     Amount  Paid 

Fig.  27. — These  round  tickets,  kept  on 
a  spindle  at  the  desk,  are  given  the  patient 
to  indicate  his  turn  for  treatment,  and  to 
avoid  confusion  in  getting  him  into  the 
Fig.  26. — Patient's  check  which  is  given  right  room.     Different  colors  indicate  dif- 
to  him  when  he  is  admitted  each  day.      ferent  rooms. 


APPENDIX 


97 


THE  YOUNGSTOWN  HOSPITAL  ASSOCIATION 

O.  P.  D. 

E<:L£*^^ 


Fig.  28. — Medical  history  card.  The  date  is  stamped  at  the  desk  on 
the  day  of  each  visit  before  the  card  is  placed  in  the  clinic  room,  thus  insur- 
ing correct  dating. 


THE  YOUNGSTOWN  HOSPITAL  ASSOCIATION 
O.  P.  D. 


Date. 
Executive  Director:— 

In  my  opinion  this  patient  should  be  admitted  to  the  hospital 
for  treatment— for  ftpti  ation. 

Diagnosis .... 


M.  D. 


Fig.  29. — Reference  slip  used  when  a  patient  is  referred  for  admission  to  the 
hospital  wards.     This  is  pink  in  color. 


I  would  recommend  that  this  patient  be  admitted  to  the 
Hospital.    Investigation  would  show  that  charge  should  be  made  to 


Patient  admitted  under  No. 


Fig.  30. — Reverse  side  of  reference  slip.     This  accompanies  the  patient 
to  the  hospital  office,  and  is  returned  with  his  admission  number,  and  is  filed 
with  his  record  in  the  Out-patient  Department. 
98 


APPENDIX 


YOUNGSTOWN  HOSPITAL  ASSOCIATION 

OUT-PATIENT  DEPARTMENT  REFERENCE  CARD 


99 


Fig.  31. — Card  referring  patient  from  the  Hospital  Ward  to  the  Out-patient 
Department  for  service. 


NOTICE 

PATIENTS  RECEIVING  THIS  BLANK  MUST  PRESENT  IT  AT  THE  OUT- 
PATIENT DEPARTMENT  DURING  THE  HOURS  OF  1O  A.  M.  TO  II  A.  M.  ON 
THE  DATE:  INDICATED  BELOW 


0 


THE  OUT-PATIENT  DEPARTMENT  IS  OPEN    FOR   THE  TREATMENT  OF 
PATIENTS  EVERY  DAY  EXCEPT  SUNDAY  AND  HOLIDAYS. 


Fig.  32. — Reverse  side  gives  definite  information  which  insures  against 
any  mistake  on  the  part  of  the  patient,  and  if  he  is  interested  in  his  own 
welfare  he  will  find  his  way  to  the  O.  P.  D.  These  blanks  illustrate  the 
unification  of  work  spoken  of  at  the  beginning  of  Chapter  II. 


IOO 


THE  HOSPITAL  AS  A  SOCIAL  AGENT 


-- 

The  Youngstown  Hospital  Association 

Out-Patient  Department 
Social  History  and  Record 


No.         Clan 


At/06 


Age 


Length" of  Time  i 


U.  S.       <V 


Support  .of  Family 


Weekly  Wage 


Name,  of  Children 


Case  No. 

yy/^i 


Ag< 


Phytical  Defect.  or  Other  Extenuating  Circumstance. 


4-4- 


rT 


RefeWTby 


*,*.*/-r 


Religion 


Fig.  33. — Family  history  blank  which  may  be  introduced  when  the  work 
in  the  O.  P.  D.  becomes  large  enough  to  justify  the  separate  record  blank. 
This  is  yellow  in  color,  and  serves  as  the  social  history  for  all  members  of  the 
family  by  referring  to  the  family  number.  Time  is  thus  saved  and  confusion 
resulting  in  different  spelling  of  the  surname,  and  the  family  becomes  a 
unit  on  the  records  of  the  department.  The  first  member  of  the  family 
admitted  establishes  the  family  number,  and  the  same  index  card  is  used 
by  adding  the  family  number  above  the  case  number. 


APPENDIX  101 


JUL26  ><)17>-     fine  igiqn^     SERB     1917 


JUL2819)7^    AUG  16  1917*^     MS«*«*^*A& 
JUL311917^    AUG  18  19i;^     ^  /^ 


AUG  2.     1917**-  AUG  2i  1917 


AUG4    1917^-  AllCP?  1017^ 


AUG  7    1917K-  AUG  25  1917 


AUG  9    1917*-     AUG291917 


AIIC11  1917^"    AUG  3  11917 


Fig.  34. — This  card  is  used  for  the  active  file  of  cases,  and  at  the  end  of 
the  year  facts  concerning  the  year's  work  may  be  made  from  these  cards. 
They  also  serve  to  keep  track  of  the  return  dates  for  patients,  as  the  ad- 
vance date  is  transferred  from  the  medical  history  card  to  this  one  each  day, 
and  notification  may  be  sent  to  patients  to  return,  or  the  case  may  be  visited. 


THE  YOCNGSTOWN  HOSPITAL  ASSOCIATION 

O.  P.  D. 


Name. 

B 


No. 

Date  . M.  D. 


Fig.  35. — Prescription  blank.    This  is  pink  in  color. 


102  "THE  HOSPITAL  AS  A  SOCIAL  AGENT" 


THE  YOUNGSTOWN  HOSPITAL  ASSOCIATION 

DENTAL    CLINIC 


ADDRESS ^ 


MARK  IN  RED,  TEETH  MISSING  ON  ADMISSION 


COMPLAINT, 


Fig.  36. — Dental  history  card. 


APPENDIX  103 


PREVIOUS  HISTORY 


HISTORY  PRESENT  TROUDLE 


EXAMINATION 


REMARKS 


REVISIT  DATES 


EXAMINED  BY 


Fig.  37. — Reverse  side  of  dental  history  card. 


104  "THE  HOSPITAL  AS  A  SOCIAL  AGE-KT" 


YOUNGSTOWN  HOSPITAL  DENTAL  CLINIC 

Patients  must  not  leave  the  Retiring  Room  until  tKe  bleeding  has  completely  stopped 

At  home  wash  out  the  mouth  with  warm  salt  water  every  Hour,  and  after  each 
meal  (Add  a  pinch  of  table  salt  to  one-half  glass  of  water  and  use  up  at  once.) 

If  bleeding  should  again  start,  the  patient  must  not  wash  out  the  mouth  as  this 
would  promote  bleeding.  Instead,  place  a  large  wad  of  clean  surgical  cotton  over 
the  extraction  wound,  and  close  the  jaws  tightly,  and  keep  closed  for  fifteen  min- 
utes by  the  watch.  If  the  bleeding  does  not  stop,  replace  the  cotton  by  a  fresh 
wad,  and  at  once  return  to  the  Hospital. 

If,  after  the  first  treatment  at  the  Hospital  relief  is  not  obtained,  or,  if  pain  has 
returned,  the  patient  is  requested  to  again  call  at  the  Hospital 

Charia  for  EitractioD :    Withoot  C«,  No  Charge.      With  CM,  SOc.      Wilk  ftorocaioe,  25c. 
Clinic  Hours :    Daily  9  to  12  and  1  to  4. 


Fig.  38. 


Decayed  teeth  are  the  cause  of  many  serious 


The  best  -way  to  prevent  decay  is  to  keep 
teeth  clean. 

Clean  teeth  are  more  essential  to  Health  than 
dean  face  and  hands. 

Teeth  should  be  brushed  after  each  meal  and 
at  bed  time. 


Fig.  39.— Reverse  side  of  Fig.  38. 


APPENDIX  105 


YOUNGSTOWN  HOSPITAL 
DENTAL  CLINIC 

CLINIC  HOURS,  6  TO  4  NO  SUNDAY  WORK 

.. _.„ has  an 

Appointment  on 


Mon  
Tues  

at  
..  at 

Thur.  
Frl  

at  
.    at 

Wed  

at  

Sat, 

.  ..  at    ..    . 

THIS   ENGAGEMENT  MUST  BE  PROMPTLY  KEPT.      FIFTEEN  MINUTES 

GRACE  18  ALLOWED.  AFTER  WHICH  TIME   IT    MAY    BE   CANCELLED 

-OVER- 


Fig.  40. 


Patient  must  bring  this  card  when  returning  to  clinic. 

The  Patient  is  expected  to  notify  the  Dentist  in  case 
of  Inability  to  keep  appointment, 

The  fees  charged  are  only  sufficient  to  cover  materials 
used  and  are  to  be  paid  at  each. visit. 


Fig.  41 —Reverse  side  of  Fig.  40 
Figs.  36-41. — A  set  of  dental  cards  used  in  dental  clinic. 


Form  8&2-3tKM2-10 

THE  YOUNGSTOWN  HOSPITAL  ASSOCIATION 

O.  P.  D. 


.NAME ADDRESS 


Obstetric  Case  Record.     Service  of  Dr.. 
Family  History _ 


Personal  History 


Previous  Obstetrical  History 

No.  pregnancies _ Miscarriages 

Easy. t _ Difficult..- Operation. 

Gynaecological  Examination— Para _ _ _ 

Date  of  last  menstruation Date  of  quickening 

Probable  date  of  confinement _..'. _ „ 

Headache _ ..Backache Oedema Bowels _.. 

Varicose  veins ...Nausea..... .Vomiting. _ Bleeding. _.. 

Breasts _ R.  Nipple L.  Nipple 

Right left _ Flat ,. 

Fissured... _ __. _ _ „ - 

_ _ -Eroded _ 

Projected.. _ 

FOETUS 

Position _ _ _ Location  of  forehead ..-Dorsal ... 

Small  Parts Size _ Presenting  part 

Rate  of  heart _ „ Where  heard - _ 

Relation  of  presenting  part  to  brim:  Above. Partly  through.- 

Bladder... „_ _ 

ABDOMEN 

SphericaL... Irregular Thick _ 

Tnln._ _ Pendulous.. .....Flaccid 

Symphysls  to  Enslform Symphysls  to  Fundus ... _ — ,._ 

Crests -..Anterior  Superior  Spines...- Trochantef - 

External  Conjugate „ _ Inter  Ischii 

External  Oblique  R _ — - • 

External  Oblique  L. _ „.. . - • • 

Uterine  Elevation. „ _ Amount  Liquid  AmniL 

106 


APPENDIX  107 


INTERNAL  MEASUREMENTS 

True  Conjugate^. _ _„...__..-._._.. -._ __Cocy«  Movable 

Tnmt.  DUro.  of  PeMs. 1 


Vuh*._ .Vagina... _ Urethra. Cystocele Rectocele _ 

Perineal  Tears _ _„ Uterus  AxlS-_..... - — 

Cervli:  Open.- _ Closed Tears.— _ 

PHYSICIAN'S  NOTES 


HISTORY  OF  LABOR 

Date Time  of  arrival  at  home Time  of  departure... 

Duration  of  labor 1st  Stage _ 2nd  Stage 3rd  Stage _ 

Position  of  head _ _ - - , - - — 

Placenta  _ _ _ 

'Character  of  pains. ._ medication , 

General  condition.. _ — Foetal  h 

Perineal  Injury  and  repair _. 


Child :  Time  of  birth. _ Weight... 

Abnormalities. - - 


Fig.  42. — Obstetric  case  record  card,  used  for  examination  of  patients 
cared  for  through  the  co-operation  of  district  nurses  spoken  of  in  Chapter  VI. 
This  is  a  folded  card  with  four  pages,  and  conforms  in  size  to  other  medical 
history  cards. 


108  THE   HOSPITAL  AS  A  SOCIAL  AGENT  " 

Forms  reproduced  above  are  distinctively  Social  Service 
and  Out-patient  Department  blanks;  #-ray,  laboratory,  and 
any  others  needed  are  those  used  in  the  hospital  for  such 
purposes. 

Four  different  colors  are  used  for  the  medical  history 
cards  (Fig.  28):  red  for  surgical;  green  for  eye,  ear,  nose, 
and  throat;  blue  for  medical,  and  white  for  orthopedic  and 
genito-urinary,  distinguishing  the  last  two  by  stamping  with 
a  rubber  stamp  at  the  top  of  the  card,  ORTHOPEDIC, 
GENITO-URINARY.  History  cards  for  the  different  clinics 
are  quickly  recognized  in  this  way,  and  as  the  little  round 
tickets  (Fig.  27)  correspond  in  color  and  title,  the  disposition 
of  patients  is  readily  accomplished. 

When  a  patient  applies  for  treatment  the  social  history 
is  taken  on  blank  form  (Fig.  20  or  33),  index  card  (Fig.  21) 
is  filled  in,  admission  card  (Fig.  22)  is  made  out  and  given 
to  him  (for  which  10  cents  is  collected),  and  he  receives  a 
"Patient's  check"  with  the  round  ticket  indicating  the  clinic. 
The  medical  card  is  then  headed  with  the  number,  name, 
address  and  date,  and  placed  in  the  clinic  room.  The 
patient  is  then  ready  for  the  doctor's  examination. 


APPENDIX 


ICQ 


CHARITY 
ORGANIZATION 

SOCIETY 

c 

0s 

0 

\ 

p 

\ 

E 

R 

_—  -~ 

A 

s* 

T 
/ 

I 

/ 
0 

\\ 

cm 

CHARITIES 

FEDERATED 
JEWISH 
CHARITIES 

VISITING 

NURSE 
ASSOCIATION 

SCHOOL  NIBSES 

CHILDREN'S 
AID  SOCIETY 

PROBATE  COIBT 
JUVENILE  COURT 

BOARD  OP 
HEALTH 

MISSION 

SETTLEMENT 

PASTORS  AND 
INDIVIDUAL 
CITIZENS 

HOSPITAL 

CARE 


TREATMENT  IN 
OUT-PAT  IZNT 
DEPARTMENT 


CLASSES  AND 
SURGICAL 
APPLIANCES 
SUPPLIED 


TRANSPOR- 
TATION 


ACCOMPANYING 

TO 

TRAINS,  HOMES 
INSTITUTIONS 


MESSAGES  TO 

FRIENDS 
LETTERS 
ADVICE 


TEMPORARY 
LODGING 


CLOTHING 
SUPPLIED 


Fig.  43. — Diagram  showing  features  in  detail  which  make  the  hospital  a 
social  agent  in  the  community. 


INDEX 


ADVERSITY,  social  service  in,  32 

BIRTHS,  illegitimate,  father  in,  51 
problem  of,  47 

CASES,  illustrative,  14,  35-39,  43,  52, 
56,  62,  63,  64,  67,  69,  73,  80 

Children,  crippled,  67 
hospital,  problem  of,  58 

rights  of  parents  in  cases  of,  60 

Chronic  disease  cases,  social  service  in, 
33 

Clinics  for  nervous  cases,  46 

Community,  social  service  to,  40 

Conservation  of  human  energy,  71 

Crippled  children,  67 

DISPENSARY,  definition  of,  18 
duties  of  social  service  worker,  21 
establishment  of,  for  clinical  uses,  18 

on  social  service  basis,  17 
field  of,  in  medical  education,  18 
obstetric  service,  62 
patient,  treatment  of,  16 
service,  patients  eligible  for,  71,  72 
work  in  tuberculosis,  44 

District  nurse  and  social  worker,  co- 
operation of,  28 

EDUCATION,  medical,  field  of  dispensary 

in,  18 

Energy,  human,  conservation  of,  71 
Epilepsy,  cases  of,  45 
Eye  diseases,  social  service  in,  85 


FATHER  in  illegitimacy,  problem  of,  51 
Feeblemindedness,  cases  of,  45 
Follow-up  work  in  social  service,  21 
Free  patient,  treatment  of,  16 

HEALTH  work,  public,  hospital  in,  79 
Home,  relation  of  hospital  social  ser- 
vice to,  14 

Hospital  as  medicosocial  agent,  20 
children,  problem  of,  58 

rights  of  parents  in  case  of,  60 
in  public  health  work,  79 
modern,  scope  of,  17 
physician,  compensation  to,  for  free 

service,  16 
social  service  department,   13,   17. 

See  also  Social  service,  hospital. 
Human  energy,  conservation  of,  71 

ILLEGITIMATE  births,  father  in,  51 

problem  of,  47 
Illustrative  cases,  14,  35-39,  43,  62,  63, 

64,  67,  69,  73,  80 
Individual,  social  service  to,  40 
Injury,  social  service  in,  32 
Insanity,  cases  of,  45 

social  service  in,  33 

KEEPING    records    in    social    service, 
forms  for,  89-108 

MALPRACTICE  in  social  service,  12 
Medical  education,  field  of  dispensary 
in,  18 

XXI 


112 


INDEX 


Medicine,  analogy  to  social  service, 

12 
Mother,  unmarried,  problem  of,  47 

NERVOUS  cases,  clinics  for,  46 
Nurse,  district,  social  service  worker 
and,  co-operation  of,  28 

OBSTETRIC  service,  dispensary,  62 
Officials,  public,  and  social  service,  77 
Out-patient  department.     See  Dispen- 
sary. 

PATIENTS  eligible  for  dispensary  ser- 
vice, 71,  72 

Physician   and   social    worker,   team- 
work between,  15 
hospital,  compensation  to,  for  free 

service,  16 

Prophylaxis  in  social  service,  12 
Public  health  work,  hospital  in,  79 

relation  of  social  service  to,  20 
officials,  social  service  and,  77 

RECORD  keeping  in  social  service,  forms 

for,  89-108 
Reference  blanks  in  social  service,  89 

SANATORIUM   in   tuberculosis,   advan- 
tages of,  44 

Sickness,  social  service  in,  32 

Social  history  of  applicant,  obtaining, 

12 

service,  11 

analogy  to  medicine,  12 
application  in  individual  cases,  12 
as  self-defense  of  society,  60 
basis  for  dispensaries,  17 
cases,  variety  of,  19 
completion  of,  to  patient,  22 
conservation  of  human  energy  by, 

71 
constructive  qualities  of,  26 


Social  service,  correlation  with  other 

social  agencies,  23 
definite  aims  of,  22 
development  of,  11,  87 
diagram  of  features,  109 
follow-up  work  in,  21 
for  crippled  children,  67 
hospital,  department  of,  13,  17 

natural  growth  of,  13 

opportunities  of,  34 

organization  of,  21 

relation  to  home,  14 
in  chronic  diseases,  33 
in  dispensary  obstetric  service, 

63 

in  epilepsy,  45 
in  eye  diseases,  85 
in  feeblemindedness,  45 
in  illegitimate  births,  47 
in  injury,  32 
in  insanity,  33,  45 
in  problem  of  unmarried  mother, 

47 

in  sickness,  32 
in  treatment  of  wounded  soldiers, 

78 

in  tuberculosis,  33,  42 
in  venereal  diseases,  80,  84 
malpractice  in,  12 
proper  limitations  of,  31 
prophylaxis  in,  12 
public  officials  and,  77 
reasons  for  existence  of,  11 
record  keeping  in,  forms  for,  89- 

108 

reference  blanks  in,  89 
relation  of,  to  other  social  agencies, 
23 

to  public  health,  20 
specialism  in,  13 
to  community,  40 
to  individual,  40 
to  society,  40 


INDEX 


Social    service    worker   and   district 

nurse,  co-operation  of,  28 
dispensary  duties  of,  21 
head,  duties  of,  21 
physician  and,  team-work  be- 
tween, 15 

qualifications  necessary  for,  21 
selection  of,  21 
Society,  social  service  to,  40 
as  self-defense  of,  60 
Soldiers,   wounded,   social   service   in 

treatment,  78 
Specialism  in  social  service,  13 


TEAM-WORK  between  social  worker  and 

physician,  15 
Tuberculosis,  cases  of,  41 
social  service  in,  33 

dispensary  work  in,  44 

sanatorium  in,  advantages  of,  44 


UNMARRIED  mother,  problem  of,  47 


VENEREAL  diseases,  social  service  in, 
80,  84 


INITIAL  FINE  OF  25  CENTS 


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